After Meb Keflezighi’s victory in the New York City Marathon last year and his fifth place in Boston this year, he will start as one of the favourites this year, though it promises to be a great race. Haile Gebreselassie will be making his New York debut, but he is in no other sense a debutante. It will fascinating to see whether or not he still has the form that carried him to the world record in Berlin in 2008. I understand that Tesfaye Jifar who set the course record almost a decade ago, will be back again this year. Among the somewhat younger contenders in New York on 7th November will be Dathan Ritzenhein . He made a rather disappointing New York debut in 2006 but is returning to New York after some strong performances on the track, and a bronze medal at the World Half-Marathon Championships in a time of 60:00 in Birmingham in 2009.
But really this blog post and the next will be about me almost as much as Dathan Ritzenhein, and the sub-title might well be ‘Will Canute be fit enough to run the Worksop Half marathon on Halloween?’ I am writing this in response to Ewen’s recent question about my prospects of running a half marathon this year in light of the fact that my year has been blighted by illness. In my return to running two weeks ago, I struggled to maintain a pace of 5 min/Km during an attempted modest tempo run. The reason for a rather far-fetched comparison of myself with one of America’s leading distance runners is that Ritz has also frequently been sidelined by injury, and if one digs a little deeper into the details, there are some interesting parallels, but also interesting differences in the way that we have responded to a similar problem.
My main problem this year has been an episode of arthritis that started in January and lingered for many months. It started in my neck, and then spread to my knees, especially the left knee. Although the acute inflammation settled several months ago, I have subsequently been plagued by a variety of irritating problems around the knee joint, especially patello-femoral pain and also irritation of the iliotibial band. I suspect that both of these problems can be attributed largely to a temporary alteration of my gait to protect the femoro-tibial joint (the main load-bearing joint at the knee) during the period when the acute arthritis was resolving. However, I think the presence of acute systemic inflammation and/or my altered gait has also unsettled several of my other long-standing trouble spots, including my metatarsals. At present my most frustrating problem is metatarsalgia.
The history of Ritz’s metatarsals
Dathan Ritzenhein has suffered metatarsal problems for years. After a promising display of talent in high school athletics, culminating in a bronze medal at the IAAF World Junior Cross-Country Championships in 2001, he had went to college in Boulder, Colorado. Following a successful freshman year, his sophomore year was blighted by two metatarsal stress fractures. The next year he won the National Collegiate cross country championship but again suffered a stress fracture, and limped home in last place in the 10,000m trials for the 2004 Olympics. Nonetheless due to various mishaps to the initially selected runners, he made the Olympic team, but dropped out halfway through the race in the Athens on account of pain from the stress fracture. After the Olympics he left college athletics to become a professional and joined Brad Hudson’s coaching group in Boulder.
Boulder is a quirky university town set in awe-inspiring but austere landscape on the eastern slope of the Rockies. I knew Boulder as it was in the days before Ritz attended college there, but I do not expect that the terrain has changed greatly in the past decade. Within the city are many paved cycle paths, including the well known creek- side path, which at first sight appears an attractive running route, but the concrete surface is very hard. Extending up into the nearby foothills is a further network of unpaved trails but these are mostly hard earth and rock. Being in the centre of the north American landmass, Boulder also happens to be more than a mile (1600m) above sea level. It is not as high as towns such as Eldoret in the Rift Valley district of western Kenya, or the mountains near Addis Ababa in Ethiopia, where high country lying between 2000 and 3000m above sea level has become a Mecca for athletes seeking the secrets of African distance runners. However Boulder’s combination of thin air, hard rocky ground and relatively few trees create an environment that is hard on the body of a serious distance athlete.
In her account of training in the mountains of Ethiopia, Hilary Stellingwerff noted ‘Finally, on all my recovery runs, the Ethiopian athletes stressed the importance of running on soft ground in the forest to make sure you go slow enough to really recover. They don’t worry too much about their pace, but instead about “getting good oxygen” from the trees and “soft ground” for the body.’ 
I will return to the question of whether or not the harshness of the environment makes an appreciable contribution to the risk of injury in a future post when I respond to Ewen’s other recent question about the value of monitoring Heart Rate Variability. However I think it is plausible that the austere environment, and especially the hard trail surfaces of Boulder contributed to several of Ritz’s injuries and illnesses over the years.
In May 2009 Ritz left Brad Hudson to joint Alberto Salazar’s group at the Nike Oregon project in Portland. Although I do not know Portland, I had lived for almost a decade in Vancouver, BC, and I am fairly familiar with the Pacific Northwest. I find it hard to imagine anywhere in the world that could be more congenial to the body and spirit of a distance runner than the moist and verdant Pacific Northwest. Added to the idyllic natural surroundings is the high tech support provided by Nike, which includes a house with artificially thinner air. The athletes can live and sleep in the rarefied atmosphere that encourages accumulation of red blood cells, yet avoid the stress of high altitude training by doing their rigorous training at normal atmospheric pressure. However even in this runners’ paradise, Ritz continued to suffer injury. So the hard surfaces of Boulder were not the only cause.
In an interview with Peter Gambaccini for the Racing News blog at Runner’s World in July of this year Salazar admitted ‘Dathan continues to have some foot problems which he’s had for years. I had thought that just by keeping him on soft surfaces and making sure that he’s recovered that this would be taken care of.’ 
In an attempt to overcome the continuing problems Salazar and the Nike team have implemented two changes. First they identified the fact that the head of Dathan’s third metatarsal on the right foot protrudes downwards. To relieve the pressure, Nike’s head of biomechanics, George Valiant, produced a hollowed-out insert for his running shoe. This produced an immediate relief which I find understandable, because I had made a similar modification to the insoles of my own running shoes about 8 years ago, and , as I will describe in my next post, this provided a partial relief to my own problems. In the interview reported in the Racing News blog Peter Gambaccini also spoke to Dathan himself. He reported ‘I feel really comfortable now. The inserts feel real good. There’s still a little bit of refining on them, but at this point, I feel like when I train daily now, it feels good and my body’s getting used to it.’
Changing from heel-striking to mid-foot landing
Salazar’s other innovation was to encourage Dathan to change from heel-striking. Alberto Salazar believes that there is a right way to run and that right way does not include heel-striking. In the interview for the Racing News blog, Gambaccini asked about the change from heel striking and Dathan replied ‘I was definitely more of a heel-striker, so I’m definitely getting on to my midfoot more. I wouldn’t say I get all the way up to my toe. I think I’m more pretty much efficient for the marathon if I stay in more of a midfoot stance anyway. ……. Initially, the problem was we tried to focus solely on changing that without being strong enough to do it. We went back to trying to build it up from the strength side so it (the stride change) naturally took over instead of trying to think about it consciously’
It is of interest to note that Ritz emphasized the necessity of building strength to support the transition from heel-strike towards the forefoot. In that interview he did not give further details, but I suspect he was referring largely to the greater calf strength required when running on the forefoot, though I wonder whether he was also referring to the necessity for greater strength of the intrinsic muscles of the foot, which are called upon to take a larger role in distributing the forces of impact. I seriously doubt Salazar’s wisdom in the decision to change from heel-striking for a runner with metatarsal problems, and will return to that issue when I focus on my own tentative approach to my metatarsal problems.
Is the heel-strike debate a red herring?
In my own speculation about running style (described in ‘Running: a dance with the devil’ in the side panel) I have advocated forefoot landing, but I believe that even more important than forefoot landing in a high cadence and short time on stance. A recent study by Heiderscheit and colleagues from Wisconsin  confirms that increasing cadence by 10% without making any conscious attempt to change other aspects of running style results in a substantial reduction in stress at knee and hip. I continue to believe that if there is one change that is worth making to running style, it is increasing cadence, at least up to a rate in the range 180-200 steps per minute. I think that above 200 there are diminishing benefits, except when sprinting. But the nagging question remains: is it also worthwhile to change from heel-strike to forefoot strike.
There are three main arguments favouring a change. First, it would be expected that landing on the forefoot will result in greater capture of the energy of impact as elastic energy in the muscles and tendons of the foot and calf, and that this energy might be recovered at lift-off from stance. Secondly, the absorption of impact energy as elastic energy will prevent the sharp rise in ground reaction force immediately after foot-strike. The jarring effect of this rise in force transmitted upwards through knee and hip might be expected to increase risk if musculo-skeletal injury, though there is little evidence supporting this. Thirdly, from the evolutionary perspective, it is probable that the human frame evolved to facilitate barefoot running, and barefoot runners usually land on mid or forefoot.
However, the extensive anecdotal evidence of increased rate of calf injuries following transition to forefoot landing suggests that the injury risk associated with the transition is high unless the runner makes a determined effort to strengthen the muscles of foot and calf. Studies such as the Capetown study of Pose  suggest that the transition can be associated with less stress at the knee, but the more recent study by Heiderscheit and colleagues  indicates that the reduced stress on the knee with Pose style might be due at least in part to increased cadence. With regard to the evolutionary argument, it might well be that forefoot striking was best suited to the barefoot running on the African savannah 2 million years ago, but most of us now run on paved surfaces much of the time. Furthermore the elegant longitudinal arch of the foot suggests to me that the human foot evolved to absorb and store impact energy efficiently when both forefoot and heel are grounded.
In principle heel -striking and forefoot striking are distinctly different, but in fact there is a continuum. At one extreme, the entire force of impact is borne by the heel; at the other extreme the impact is taken entirely on the forefoot. I consider that both of these extremes are likely to increase risk of injury. In the middle of the range is mid-foot striking in which the initial impact is taken equally on forefoot and heel. In this style, the impact forces within the foot are immediately distributed along the length of the longitudinal arch. But of course, the runners’ stance is a dynamic event in which the peak vertical ground reaction force occurs around mid-stance, and perhaps that it the point at which it is most beneficial to have both forefoot and heel grounded.
If one is aiming to have both forefoot and heel grounded around midstance, the possibilities for ankle posture at foot-strike stance range from plantar flexion to mild dorsiflexion, but I suspect that the factor that plays the greatest role in determining the softness of the landing is the degree of flexion of the knee. As the knee flexes at impact, the quads, which are far bulkier than any muscles below the knee, will absorb impact energy. If the degree of tension in the quads is low, the landing will be soft and the risk of injury low, but the recovery of elastic energy will be relatively slow. If higher tension is maintained in the quads, the leg will act like a stiff spring, retuning energy rapidly and promoting efficiency, at the price of somewhat greater initial rate of rise of the vertical ground reaction force and possibly greater risk of injury.
I suspect that there is an inevitable trade-off between efficiency of energy recovery and risk of injury, determined largely by the amount of tension in the quads. I also suspect that for a long distance runner, the orientation of the ankle matters relatively little provided it is within the moderate range that allows an equable dissipation of impact forces along the longitudinal arch by midstance. If so, the heel-strike v fore-foot debate is largely irrelevant, unless the athlete has anatomical features that make a particular part of the foot more vulnerable. For a runner with downward protruding metatarsal heads, I suspect that a mild degree of heel-strike might actually be preferable.
I have taken a particular interest in the way Dathan Ritzenhein has dealt with his problem because I have faced some similar issues. By trial and error I had discovered some of the same strategies as Ritz, though in one potentially important respect I have taken a different path. But this post is already long enough so I will defer the history of my own metatarsal problems to my next post.
 Heiderscheit, BC.; Chumanov, ES.; Michalski, MP.; Wille, CM.; Ryan, MB (2010) Effects of Step Rate Manipulation on Joint Mechanics during Running. Medicine & Science in Sports & Exercise: doi: 10.1249/MSS.0b013e3181ebedf4; Jun 23. [Epub ahead of print]
 Arendse RE Noakes TD, Azevedo LB, Romanov N, Schwellnus MP, Fletcher G. (2004) Reduced Eccentric Loading of the Knee with the Pose Running Method. Medicine & Science in Sports & Exercise: Vol 36 pp 272-277