Running and foot pain…treatment and prevention of Plantar Fasciitis

Running And Foot Pain
Distance Running Tips

Running and foot pain… If I had a dollar for every runner I knew who had a foot running injury, I'd have a fat bank account!

Plantar Fasciitis, the most common running injury of the foot, may cause the heel to hurt, feel hot or swell, is inflammation of the plantar fascia, a thin layer of tough tissue supporting the arch of the foot. Repeated microscopic tears of the plantar fascia cause pain. Sometimes plantar fasciitis is called "heel spurs", but this is not always accurate, since bony growths on the heel may or may not be a factor.

Diagnostic testing, such as X-rays, usually is not necessary to diagnose plantar fasciitis, although it may be useful to rule out other potential causes of running and foot pain. Typically with plantar fasciitis, the pain is worse when first getting out of bed, or is noticeable at the beginning of an activity and gets better as the body warms up. Prolonged standing may cause pain, as well. In more severe cases, the pain may worsen toward the end of the day.

Causes: There are a number of possible causes for plantar fasciitis. The most common cause of running and foot pain is very tight calf muscles which leads to prolonged and/or high velocity pronation of the foot. This in turn produces repetitive over stretching of the plantar fascia leading to inflammation and thickening of the tendon. As the fascia thickens it loses flexibility and strength.

Other causes include high arch or low arch feet and other bio-mechanical abnormalities which should be assessed by a podiatrist or physiotherapist who are specialists in running and foot pain.

Treatment: Symptoms usually resolve more quickly when the time between the onset of symptoms and the beginning of treatment is as short as possible. If treatment is delayed, the complete resolution of symptoms may take 6-18 months or more. Treatment will typically begin by correcting training errors, which usually requires some degree of rest, the use of ice after activities, and an evaluation of the patient’s shoes and activities. For pain, non-steroidal anti-inflammatory drugs (e.g. aspirin, ibuprofen, etc.) may be recommended.

Next, risk factors related to how the patient’s foot is formed and how it moves are corrected with a stretching and strengthening program. If there is still no improvement, night splints (which immobilize the ankle during sleep) and orthotics (customized shoe inserts) are considered. Cortisone injections are usually one of the treatments of last resort, but have a success rate of 70% or better. The final option, surgery has a 70-90% success rate. The treatment of choice has become the strassburg sock and it works while you sleep.

Fortunately I've only had a couple of episodes with plantar fasciitis. The first time it was severe… the worst running and foot pain I had experienced. What worked for me was a Plantar Fasciitis foot taping along the bottom and sides of the foot.

I kept the strapping on for the recommended week, (even leaving it on to bathe) and I was able to run pain free. After the one week, I didn't need the taping anymore. It really it works!
 

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Bone Bruise: I have been susceptible to bone bruises on the ball of my feet. Most people recommend gel pad cushioning. What works better for me is a simple basic sponge cut so that it fits over the ball of the foot. But of course everyone is different. The key is to experiment and find out what works best for you.

I've also took the insert from one of my old running shoes, cut it in half and put that in my shoe for added support.

Currently I've had to deal with this (along with a nagging plantars wart) for the past four months. Using a sponge or insert along with well cushioned shoes keeps me on the road, so it's only a minor annoyance.

About plantars warts… I finally got rid of it using Dr Scholl's Clear Away. It uses the salicylic acid method along with cushioning pad. Ater about three weeks of using this product, the wart fell off.

CoolRunning.com has additional running tips about running and foot pain that will help keep you running injury free.

 

 

Where can I get good cross-training shoes with medial posting?

I have running shoes with it but need cross-training shoes for other activites like basketball or tennis. I have plantar fasciitis so I got these special shoes for running but the store did not carry them in cross training.

Strength training and interval training for runners

By: Daniela Nahas

With the good weather fast approaching, there are many runners coming out of hibernation. I thought it only appropriate to speak about how strength training and interval cardio training can increasing your speed, stamina and prevent injury down the road.

Prevent injury: Running is great for building cardiovascular strength, however it also puts a lot of strain and impact on your body and not just the lower extremities. The body should be looked at as one fluid machine with many parts working towards one common goal ? in this case running effectively. If one of those parts is weak, it will not only affect your speed and strength as a runner, but also begin a domino effect of sprains, strains and injury.

If you plan to have a long life as a runner, it is necessary that you work on strengthening the muscles that are commonly weak in runners: this includes the glutes, the hip flexors (which do a tremendous amount of work while you run and enable the upward movement of the knee), tibialis anterior, your quadriceps and of course your core/trunk stabilizers.

Your core muscles run the length of the trunk and torso – when they contract they stabilize the spine, pelvis and shoulder girdle to create a solid base of support. This support then enables us to transfer energy from the center of the body out to the limbs and generate the movement needed for running. Core training supports the efficient interaction of the ankle, knee, and hip mobility.

Muscles included in the core are: Rectus Abdominis (located at the front of your absomen, Transverse Abdominis (are the deepest abdominal muscles located under the obliques – which wrap around the spine for support, Multifidus (under the erector spinae along the vertebral column (sacrum to axis), these muscles help extend and rotate the spine), External Obliques (run along the side and front of the abdomen) and Internal Obliques (located beneath the external obliques and run in the opposite direction, Erector Spinae (group of muscles and tendons that run along your neck to your lower back).
The hip Flexors, hip adductors and gluteus are also considered to be part of the core stabilizers.

If any of these muscles are weak, it can have a big impact on your form while running: If the hip abductors are weak for example, it can cause the entire leg to overpronate. Some common injuries include anterior knee pain, patellar tendonitis, shin splints, plantar fasciitis, stress fractures, achilles tendonitis, IT band tendonitis, low back pain, and various strains and sprains.

Furthermore, strengthening your core will not only help you as a runner, but also in everyday activities. Since we are not always moving in the same plane when we perform everyday activities, training the body to stabilize, control, and produce force in a three-dimensional environment is crucial.

Increase stamina: Many runners generally train at one consistent speed for a certain time. While this is great exercise in itself you may have a hard time increasing your stamina. Interval training which involves doing quick and intense burst of activity followed by periods of lower intensity, allows you to rapidly increase your cardiovascular endurance and improve your VO2 Max – which that describes how much oxygen your body can transport during exercise or activity. The higher your VO2 Max, the less winded you become during exercise. Translating this into your running routine, you will increase your speed and power and be able you to run for longer durations.

Weight loss: Many people who run, began running in the first place in order to lose weight and then continue to run to keep it off. However many find that after a while of just running your body begins to plateau and you stop losing any pounds and also find that you need to run much longer distances to stay trim. This is because doing solely Aerobic activity will not help you increase your metabolism. Anaerobic activity on the other hand does. It increases your lean muscle mass as well as your resting metabolic rate (your metabolic rate while at rest).

Anaerobic activity includes weight/strength training and sprinting, while running is aerobic activity.  Anaerobic activity increases lean muscle mass while aerobic activity for long durations of time breaks it down. Quite simply, muscle burns fat and anaerobic activity creates muscle, while aerobic activity does not promote the increase of muscle and actually breaks down lean muscle mass.

I am not by any means saying that you should not run, I am impressed everyday by people who are able to run marathons, and people who turn their life around when they begin running. I am simply saying that you should incorporate other components into your routine.

Have a great run!

Preventing and Treating Running Injuries

By: Seamus Kennedy, BEng (Mech), CPed

Running has been referred to as the king of all workouts. It is an activity that has been embraced at varying levels of competence by nearly 11 million adults in the United States alone, according to the American Running Association. Running doesn't require the purchase or use of expensive equipment; it is possible to do it indoors or outdoors, usually year round. Not only does running provide a fantastic cardiovascular workout, it allows you to burn calories and clear your mind, leaving you with that relaxed, feel-good sense for many hours afterward. However, to reap these benefits on an ongoing basis, it is important to take precautions to prevent debilitating injuries.

For all the benefits of this great activity, there is no doubt that the repetitive nature of the stress it places on key joints can lead to breakdown. While there is some debate about what constitutes an injury, it has been estimated that up to 70 percent of runners will sustain some form of overuse injury during any one-year period. Anyone working in the orthotics, biomechanics, or sports medicine professions will see his or her fair share of running injuries. These injuries can be broadly classified as acute or chronic. Acute injuries are those due to sudden motions or twisting, such as an ankle sprain, which lead to soft tissue and/or osseous injury. These need to be treated immediately and allowed to heal.

Chronic injuries develop over time and are the result of repetitive stress that eventually leads to breakdown; e.g., patellofemoral syndrome. Chronic injuries account for well over 80 percent of running injuries, and they can develop from either an anatomical cause or a biomechanical issueand sometimes a combination of both. Because of its impact forces on the body, running greatly magnifies the extent of these anomalies. When experienced runners develop a chronic injury, it is often necessary to investigate what they have changed in their training practices.

To get a clear picture of any injury, it is necessary to do a full biomechanical exam. Evaluate the patient in stance and motion, non-weight bearing and weight bearing, in shoes and out of shoes. It is vital to follow the entire kinetic chainnot just treat the symptomto investigate the root cause of the problem. John Connors, DPM, a New York-based sports-medicine specialist, insists on watching his patients function in order to determine underlying causes. He will even run with his world-class patients in order to diagnose their etiology.

Common Running Injuries

Heel pain: Heel pain is a common complaint among runners. This is hardly surprising, given that the majority of runners who train on level ground at low to moderate speeds are heelstrikers. This running style produces an impact-force peak early in the stance phase, which can range from one-and-a-half to five times the runner's body weight. These impact forces are considered a primary cause of overuse injuries.

The classic sign of plantar fasciitis (PF) is heel pain that presents first thing in the morning and then decreases with activity. In the early stages, the patient usually can still exercise, only to be faced with more severe pain following a run. Typically, pain will be felt at the plantar-medial aspect of the calcaneus or at the middle aspect of the calcaneus.

There are other causes of heel pain that should not be ruled out without further radiographic examination. A calcaneal stress fracture may present like PF, but typically the pain does not subside as the day progresses. A positive calcaneal compression test can indicate the presence of such a fracture. Other considerations for heel pain include tarsal tunnel syndrome, neuritis of the first branch of the lateral plantar nerve, and tendinitis of the flexor hallucis longus.

Achilles tendinitis (AT): Achilles tendon injuries may be due to inflammation of the paratenon or the result of the degeneration of the tendon itself. It is broadly classified into two groups: insertional (occurring at the tendon/bone interface) and non-insertional (occurring proximal to its insertion, in or about the tendon proper). A physician's diagnosis will confirm the location and type of condition. AT can develop when the tendon contracts and tightens and is then over-stretched during exercise. There may also be a biomechanical component to the condition, given the tendon's broad insertion on the posterior calcaneus. Due to the cyclic rotation of the STJ from pronation through supination, there can be increased tension on the medial and lateral aspects of the tendon's insertion.

Iliotibial band syndrome (ITBS): This is a debilitating injury that presents as pain along the lateral aspect of the knee joint. It is sometimes accompanied by a clicking sensation. Current thinking is that ITBS results from weak core and hip muscles that fail to prevent tightening and strain the IT band.

Medial tibial stress syndrome (MTSS): Commonly known as "shin splints," this pain is typically noted along the lower third of the posterior medial surface of the tibia. It can often result from improper biomechanics or by not following the training considerations described earlier.

There are many other injuries that you are likely to see in runners such as posterior tibial tendon pain, knee pain, and a variety of stress fractures. Forefoot pathologies can include functional hallux limitus, sesamoiditis, and second metatarsal phalangeal joint (MPJ) capsulitis, in addition to regular blisters, corns, and neuromas. Much has been written on each of these conditions and their specific rehabilitation treatments. "How to Detect and Treat Running Injuries," by Brian Fullem, DPM, (Podiatry Today, May 2005) covers the basics. It is an excellent resource.

Preventative Measures

Over the years, I have developed a great love for running, so I can say from personal experience as well as patient interaction that nearly all running injuries result from training errors. I try to follow my own advice on injury prevention as outlined above. I begin a run by forcing myself to stretch; I change out my running shoes as necessary, even if they look almost new; and I vary my workouts with swimming, yoga, and sometimes bicycling to ensure adequate rest. I am pleased to say that I am injury free. However, when injuries do occur, treatment will generally follow a protocol of relieving pain, resting, icing, stretching, focused strengthening, and improving biomechanics. Good support from shoes and orthotics, good running form, and good training habits, such as always stretching, will prevent the return of many of these injuries. I believe foot orthotics, whether custom or not, play an essential role in keeping a runner injury free by aligning the body properly. Regardless of foot type, appropriate orthotics will increase shock absorption and prevent end-of-range-of motion, thus protecting tendons, muscles, and joints.

Another strategy for preventing running injuries is to advise your patients to modify their running style. Recently, I have begun using a technique called ChiRunning© ( www.chirunning.com). In essence, ChiRunning aims to lessen the forces that most runners experience by introducing a slight forward lean and a biomechanically efficient flow to their running style. It advocates running with relaxed lower legs and using a mid-foot strike to avoid the braking and impact of heel strike. Since adopting the ChiRunning approach, I have found running even more enjoyable, not to mention less strenuous.

Hopefully, armed with this information and more, you can help your runners achieve their goals.

Séamus Kennedy, BEng (Mech), CPed, is president and co-owner of Hersco Ortho Labs, New York, New York. He can be contacted via e-mail atseamus@hersco.com, or visitwww.hersco.com

Training Considerations

Increasing mileage and/or speed: Make any changes in distance or tempo gradually.

Breaking in new shoes: Break in new shoes slowly over a few runs. Ensure that the last and sole design match the runner's foot type; i.e., pronator, supinator, or normal/neutral.

Running in old or worn-out shoes: It is recommended that runners switch out their sneakers every 300-500 miles. If sneakers are over-worn, they lose shock absorption and their ability to control rearfoot and subtalar joint (STJ) motion.

Running on unforgiving surfaces: Elite runners usually avoid running on roads too often due to the unrelenting hard surface and the banked edges. It is best to look for firm trails with some forgiveness, such as dirt, woodchips, fields, or boardwalk. Slightly uneven terrain also helps avoid an exact repetition of each stride.

New running style: Any change in running technique should be applied slowly, to allow the body to adapt.

Be aware that a change in weight, and even aging, can contribute to the onset of an injury.

 

To Stretch Or Not To Stretch

Author: Stan Reents, PharmD

If the average person was asked to define "fitness", he/she might point to the ability to run a distance race (ie., "aerobic fitness") or the ability to lift a large amount of weight (ie., "muscular strength"). But, flexibility is a component of fitness too, even though it may not get as much attention or respect as its siblings.

This brings us to the concept of stretching. Almost all athletes — from elite athletes down to the weekend warrior types — stretch. Thus, it seems intuitive that stretching prevents injuries….why else would everybody be doing it, right?

Indeed, recent studies have shown that stretching can influence the viscosity of the tendon and make it significantly more compliant. Thus, many believe that increasing the flexibility of a muscle-tendon unit promotes better performances and decreases the number of injuries. Because of this belief, stretching exercises are regularly included in warm-up and cooling-down exercises. However, the sports medicine literature is divided on whether stretching prevents injury.

But, before we get into the science, let's review some basics:

TYPES OF STRETCHING

To be precise, stretching can be classified into 5 different types:

• Ballistic Stretching: This is defined as: rapid lengthening (stretching) of a muscle by the use of jerking or bouncing movements, for example, bouncing down to touch your toes. This type of stretching is not recommended. In fact, it mimics the type of sudden stress that produces muscle injuries in the first place. Jerking a muscle into a full stretch causes it to lengthen beyond a safe stretch and may injure the muscle…exactly the opposite of what you are trying to achieve with stretching.

• Static Stretching: This type of stretching is characterized by a slow and sustained (eg., for 15-60 secs) lengthening of a muscle by the athlete without help from a partner. This is one of the best types of stretching because it does not pose the risk of injury to muscle and connective tissue as ballistic stretching does.

• Passive Stretching: Passive stretching is identical to static stretching, except that a partner is used to gradually move the arm or leg. The advantage of using a partner is that a greater range-of-motion can be achieved compared to stretching without a partner.

• Isometric Stretching: Isometric stretching is simply static stretching with the aid of an immovable object.

• Proprioceptive Neuromuscular Facilitation (PNF) Stretching: PNF stretching sounds more complicated than it really is. Technically, PNF stretching involves passive muscle lengthening with the use of a partner after an antagonistic muscle is contracted. PNF stretching is considered to be an excellent technic however the risk of injury is slightly greater than the other methods since the range of the stretch can be greater.

STRETCHING TO IMPROVE FLEXIBILITY

One of the benefits of stretching is that it does improve flexibility, albeit, short-term. Stretching, combined with warming up, has been shown to increase the flexibility of the ankle, hip, and knee joints (Thacker SB, et al. 2004). However, an improvement in flexibility does not automatically mean fewer injuries or improved athletic performance. This is where there is confusion in the literature.

STRETCHING AND MUSCLE PERFORMANCE

As mentioned above, while stretching does increase the flexibility of specific joints, greater flexibility, in turn, does not always lead to improved performance. After static stretching, the muscle-tendon unit is weaker for 10-15 minutes (or longer, see below). This phenomenon has been called the "stretch lag" period, or, "tendon slack".

In fact, in some cases, stretching actually worsens (measurements of) muscle performance. Stretching has been shown to impair maximal voluntary contraction force (Behm DG, et al. 2001), muscular endurance (Kokkonen J, et al. 2001), and one-repetition maximum (Kokkonen J, et al. 1998) when it occurs just prior to the performance assessment.

A study of 40 females using a vertical jump test to assess muscle performance revealed that adding PNF stretching to a general warm-up routine worsened jumping ability (Church JB, et al. 2001).

Another study shows the effect of stretching on muscular strength over time (Fowles JR, et al. 2000). Subjects performed 13 stretches of the plantar flexors, holding each stretch for 135 seconds during a period of 33 minutes. Maximal voluntary isometric contraction (MVIC) was assessed 6 times during the ensuing 60 minutes. MVIC was depressed as follows:

Time / Percent Strength Decrease

• Time 0: -28%
• 5 min: -21%
• 15 min: -13%
• 30 min: -12%
• 45 min: -10%
• 60 min: -9%

The authors concluded that an intense prolonged stretch (of the plantar flexors) reduces maximum voluntary force for up to 1 hour after stretching.

STRETCHING TO PREVENT INJURIES

Contradictory findings regarding the ability of stretching to prevent injuries have been reported in the literature. Stretching recommendations are clouded by misconceptions and conflicting research reports. Apparently, no scientifically based prescription for stretching exercises exists (Witvrouw E, et al. 2004).

One fundamental issue to consider is that, even though stretching improves flexibility, most injuries occur during an extremity's normal range of motion (ie., during eccentric contraction). Thus, it is illogical to conclude that improving flexibility will prevent most muscle injuries (Shrier I. 2000).

In 1999, Shrier reviewed the literature on stretching to prevent injuries. He found 12 papers with acceptable study design. Of those, 4 showed that stretching was beneficial, 3 showed that stretching was detrimental, and 5 showed no difference (Shrier I. 1999).

Australian researchers reviewed the literature in 2002 and found that stretching had no beneficial effect on delayed-onset muscle soreness (DOMS) and did not reduce the risk of injury (Herbert RD, et al. 2002).

A subsequent literature review, published in 2004 (Witvrouw E, et al. 2004), was much more revealing. These authors proposed a possible explanation for why there is disagreement on the issue of whether stretching prevents injury:

Witvrouw and colleagues believe that the type of sports activity in which an individual is participating needs to be considered. Sports that involve a lot of bouncing and jumping activities with a high intensity of stretch-shortening cycles (SSCs) (eg. basketball, football, soccer, tennis) require a muscle-tendon unit that is compliant enough to store and release the high amount of elastic energy that benefits performance in such sports. If the muscle-tendon unit is not compliant enough, the demands in energy absorption and release may rapidly exceed its capacity. This may lead to an increased risk for injury of this structure. Thus, when a sport demands stretch-shortening cycles (SSCs) of high intensity, such as jumping or abrupt changes in direction, stretching may be important for injury prevention.

In contrast, when the type of sports activity contains low-intensity, or limited SSCs (eg. cycling, jogging, swimming), there is no need for a very compliant muscle-tendon unit since most of the forces come from active muscle contraction to generate motion. Strong evidence exists that stretching has no beneficial effect on injury prevention in these sports.

In other words, whether or not stretching prevents injury depends on the type of activity being considered.

Witvrouw and colleagues believe that if this point of view is used when examining research concerning stretching to prevent injuries, the reasons for the contrasting findings in the literature are in many instances resolved.

USE OF STRETCHING TO HASTEN RECOVERY AFTER AN INJURY

While stretching to PREVENT an injury is not always helpful, the use of stretching to hasten recovery AFTER an injury has been shown to be beneficial:

• Hamstring Injuries: A Greek study randomized athletes with hamstring strains to light stretching (once per day) or a more vigorous program (4 times per day). The study was conducted from 1996-2001 and randomized 40 athletes into each of the 2 plans. All 80 athletes received RICE (rest, ice, compression, and elevation). The stretching involved static stretching for 30 seconds per stretch session.

The authors found that normal range-of-motion was achieved earlier in the 4 times per day group (5.6 days vs 7.3 days) and the time elapsed prior to achieving full athletic activity was also shorter in the 4 times per day group (13.3 days vs 15 days) compared to the once/daily group (Malliaropoulos N, et al. 2004.).

• Plantar Fasciitis: For plantar fasciitis, also known as "painful heel syndrome" or "proximal heel pain", stretching of the Achilles tendon has been shown to be beneficial in reducing pain, stiffness, and increasing range-of-motion (McNair PJ, et al. 1996; Porter D, et al. 2002). One study reported that a non-weight-bearing stretch of the plantar fascia was better than the classic standing Achilles tendon stretch (DiGiovanni BF, et al. 2003).

SUMMARY

Thus, while there still is some controversy regarding stretching to prevent injury, some conclusions can be offered:

• Stretching to PREVENT injury is most helpful in sports that involve sudden changes of direction, such as football, soccer, or tennis or sports that require lots of jumping such as basketball or volleyball. Stretching appears to be less helpful in sports that produce less shock to the muscles, such as cycling, jogging, or swimming.

• Do not stretch extensively (if at all) within 15-60 minutes prior to a competitive event.

• If you do stretch prior to a competitive event, work that muscle group for a few minutes to help the muscle(s) recover to their normal length and power capacity. For example, if you have just stretched your hamstrings and the front of your thighs to get ready for a race, do some light jogging for several minutes before the race begins.

• Avoid ballistic stretching: It is more likely to cause injury than other technics.

• Stretching injured muscles does appear to hasten recovery.

FOR MORE INFORMATION

A very succinct, yet thorough, review of the sports medicine literature on stretching was published in the Sept./Oct. 2002 issue of ACSM's Health and Fitness Journal (see Bracko MR, below). Although this publication is intended for sports medicine professionals, the article is written in an easy-to-understand style.

For a "how-to" book filled with diagrams, get the classic Stretching by Bob Anderson. Even though this book was originally published in 1980, it demonstrates every kind of stretch and stretching routine you can imagine.

REFERENCES

Behm DG, Button DC, Butt JC. Factors affecting force loss with prolonged stretching. Can J Appl Physiol 2001;26:261-272. Abstract

Bracko MR. Can stretching prior to exercise and sports improve performance and prevent injury? ACSM's Health and Fitness Journal 2002;6:17-22. (no abstract)

Church JB, Wiggins MS, Moode FM, et al. Effect of warm-up and flexibility treatments on vertical jump performance. J Strength Cond Res 2001;15:332-336. Abstract

DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003;85-A:1270-1277. Abstract

Fowles JR, Sale DG, MacDougall JD. Reduced strength after passive stretch of the human plantar flexors. J Appl Physiol 2000;89:1179-1188. Abstract

Herbert RD, Gabriel M. Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review. BMJ 2002;325:468. Abstract

Kokkonen J, Nelson AG, Andrew C. Acute muscle stretching inhibits maximal strength performance. Res Quart Exerc Sport 1998;69:411-415. Abstract

Kokkonen J, Nelson AG, Arnall DA. Acute stretching inhibits strength endurance performance. Med Sci Sports Exerc 2001;33:11A. (no abstract)

Malliaropoulos N, Papalexandris S, Papalada A, et al. The role of stretching in rehabilitation of hamstring injuries: 80 athletes follow-up. Med Sci Sports Exerc 2004;36:756-759. Abstract

McNair PJ, Stanley SN. Effect of passive stretching and jogging on the series elastic muscle stiffness and range of motion of the ankle joint. Br J Sports Med 1996;30:313-317. Abstract

Porter D, Barrill E, Oneacre K, et al. The effects of duration and frequency of Achilles tendon stretching on dorsiflexion and outcome in painful heel syndrome: a randomized, blinded, control study. Foot Ankle Int 2002;23:619-624. Abstract

Shrier I. Stretching before exercise does not reduce the risk of local muscle injury: a critical review of the clinical and basic science literature. Clin J Sports Med 1999;9:221-227. Abstract

Shrier I. Stretching before exercise: an evidence based approach. Br J Sports Med 2000;34:324-325. Abstract

Thacker SB, Gilchrist J, Stroup DF, et al. The impact of stretching on sports injury risk: a systematic review of the literature. Med Sci Sports Exerc 2004;36:371-378. Abstract

Witvrouw E, Mahieu N, Danneels L, et al. Stretching and injury prevention: an obscure relationship. Sports Med 2004;34:443-449. Abstract

ABOUT THE AUTHOR

Stan Reents, PharmD, is a former healthcare professional. He holds Personal Trainer and Lifestyle Counselor certifications from the American Council on Exercise and has been certified as a tennis coach by USTA. He is the author of Sport and Exercise Pharmacology (published by Human Kinetics).