Thanks for the great article, John! Take a few minutes and read on. This is a nicely summarized article on why foot care will help help us reduce injuries as runners.   

FootAnatomy2Feet are generally underappreciated. We cover our feet in shoes. We often hide our feet for some unknown reason, yet our feet are the primary anatomical structure which allows us to run. While nearly all other animals travel on four legs, humans, birds, some apes, lizards, and cockroaches (at their highest rate of speed) travel on two legs. Humans walk and run with a highly efficient bipedal (on two legs) gait. Long distance running on two legs is possible thanks in large part to our amazing foot anatomy. Understanding foot anatomy will lead to an appreciation of the job our feet do during every running stride.

The human foot contains 26 bones (28 if you count the two floating sesamoid bones on each foot). The bones of the foot form three distinct structural and functional units. The rear foot is made up of the large calcaneus and talus. The rear foot is built for weight bearing and articulates with the lower leg bones (tibia, fibula). The mid foot is made up of the navicular, talus, and cuneiform bones. The mid foot has a dual role. It absorbs shock during weight bearing and forms the stability we rely on (the arch) when pushing off to initiate the next step. The fore foot is made up of the five metatarsal bones and 14 bones in our toes (phalanges).

Foot function is responsible for the unique shape of each bone within the foot. The wedge-shaped mid foot bones allow shock absorption during pronation (weight bearing acceptance), but with muscle contraction the flexible wedge becomes a rigid supporting structure which drives body propulsion. In contrast, the beefy calcaneus and talus are weight bearing structures. Even though mid fFootAnatomy1oot and fore foot running has been shown to be more efficient and decrease running injuries, humans naturally heel strike when we walk. Finally, the fore foot is the region of the foot which allows us to “feel” the road or trail when we run. Balance, agility, and proprioception are duties of the fore foot.

The skeletal anatomy of the foot must be combined with the stability and mobility provided by our connective tissue (ligaments, tendons, fascia) and muscular tissue (Intrinsic: within the foot; Extrinsic: lower leg muscles). The ability to react to uneven surfaces in a fraction of a second and rhythmically run without active concentration is made possible by the neuromuscular (nerves activating muscles) component of the foot. Continuous, two-way nerve messages from and to the foot to the spinal cord and brain result in split-second shock absorption, foot agility, and propulsion power.AnkleEx3

Given the anatomical and physiological complexity of the foot, it is no wonder runners frequently experience foot and ankle pain. Foot and ankle specific exercises and basic foot care will reduce your overuse injury risk. The average human travels 100,000 miles on their feet in a lifetime. Runners can multiply this number by a factor of two! Running places 2.5 to 5.0 times the weight of the body through each foot strike, depending on gait efficiency. Impact alone can break down the structural inteAnkleEx1grity of the foot, including the joints, connective tissue, and muscular integrity. The greatest enemy of the foot, however, is torsion. Bones, joints, and connective tissue are happy when movement is through designated movement planes. Torsion through a joint, or musculotendinous structure, however, greatly increases its chance of fatigue, overuse, and injury. Stress fractures are often the result of excessive torsion through a bone secondary to inadequate stability (muscle weakness or lack of connective tissue tensile strength).

To prevent structural failure and subsequent injury in the foot, attention must be regularlAnkleEx2y placed on addressing foot-related strength, proper joint mobility, and tissue recovery. Yes, TLC is the best medicine for happy, healthy feet to allow you to run. Below are two examples of foot exercises designed to combine mobility andstability for foot injury prevention and treatment (find these images HERE on RE’s website). Call or email Sapphire Physical Therapy to find out how our staff can help prevent and treat foot-related injuries to enable you to achieve your 2016 running goals!

John Fiore, PT
Sapphire Physical Therapy

Dry Needling is a specialized service offered by Sapphire Physical Therapy. I am often asked how dry needling works and how it differs from acupuncture treatment. Due to the success I have personally had with both patients and in treating my own running-related overuse issues, I will explain what dry needling is and how it complements our fundamental physical therapy treatment methods. ~John Fiore, Sapphire PTimage


Dry needling is an effective soft tissue and musculoskeletal treatment technique to reduce pain associated with running-related injuries. Dry needling has been offered by Sapphire Physical Therapy for nearly three years. Licensed physical therapists with additional, specialized dry needling training are now incorporating dry needling into physical therapy treatment plans with impressive results. All dry needling treatment approaches and methods, however, are not alike. Understanding the science behind dry needling and an extensive knowledge of human neuromuscular anatomy is vital to successful dry needling treatment. Dry needling utilizes acupuncture needles as treatment tools, but should not be equated with acupuncture. Acupuncture has been practiced for thousands of years and is a systemic (whole body) treatment approach. Acupuncture is based on the Yellow Emperor’s Canon of Internal Medicine which was written between 206 BC and 220 AD. The Canon integrated various channel theories into one system based upon the limited neuroanatomical knowledge of the time.i Yun-tao Ma, PhD (who trained me in 2013-2014 and who founded the American Dry Needling Institute) has bridged the gap between ancient Chinese acupuncture philosophies and the neuroanatomical knowledge of western medicine to create the integrative dry needling treatment approach. Based on the cellular biology of tissue healing and its relationship with the peripheral and central nervous systems of the body, Dr. Ma has facilitated safe, effective dry needling techniques to reduce pain and stimulate tissue healing in the physical therapy outpatient setting. I was fortunate to receive my dry needling training from Dr. Ma and I now utilize integrative dry needling in my physical therapy practice. If you have struggled with a persistent running injury, suffer from acute or chronic musculoskeletal pain, experience frequent headaches, back or neck pain and are otherwise in good health, dry needling is an effective, virtually pain-free treatment used in conjunction with physical therapy therapeutic exercise and manual therapy techniques.


Various theories have existed for thousands of years for the presence of tender points or trigger points in predictable locations throughout the body. Treating such tender points (acupressure points) released tension and eased pain. What ancient practitioners did not realize, however, is the fact that pressure through a sensitive acupressure point stimulates a sensory nerve ending. The sensitized sensory nerve relays a message to the spinal cord where the central nervous system transmits the information to the brain. Sensory input is processed in the brain and a range of neurobiological events are set into action depending on how the stimulus is perceived. Dry needling, therefore, activates the body’s natural healing potential by specifically targeting and balancing the sympathetic and parasympathetic nervous systems to facilitate healing on a cellular level (at the site of the needle insertion or the injured body area). Dry needling also stimulates parts of the brain (via the hypothalamus) which activate the principle survival mechanisms (the nervous, endocrine, immune, and cardiovascular systems) and normalize the physiological activities of the whole body.ii iii


Dry needling treatment utilizing the Integrated Neuromuscular Acupoint System is painless approximately 80% of the time. While some practitioners “manipulate” the needle upon insertion, pain-free insertion of the needle alone initiates the self-healing process without the unnecessary pain to the patient which occurs during needle manipulation. Integrative dry needling results in complete resolution of symptoms in 28% of cases, resolution of symptoms for six-months or more in 64% of cases, and marginal results in just 8% of cases.iv Dry needling treatment begins with a Quantitative Evaluation to determine the distribution of acupoint sensitivity in two key body areas (lateral forearm H1point & lateral lower leg H4 point). The distribution of sensitive acupoints effectively predicts the number of recommended treatments. Running injuries (acute and chronic in nature), musculoskeletal pain, tendonitis, tendinosis, joint pain, back and neck pain, muscular guarding, delayed onset muscle soreness, cumulative stress (overuse injuries) injuries, and joint stiffness all respond remarkably well to dry needling treatment. Dry needling indirectly improves the effectiveness of running-specific weight bearing strengthening exercise and manual therapy techniques by reducing chronic compensatory movement patterns resulting from stiffness, tightness, and pain.


Following a comprehensive medical history screen and physical therapy objective evaluation (functional testing, range of motion testing, strength testing, video running gait analysis), dry needling may be determined to be an effective component of your treatment. In addition to treating restricted, painful, or injured areas, a sequential series of key body locations (homeostatic points) may be included in the dry needling treatment. Treating of the body’s 24 homeostatic points restores homeostasis in the body and boosts our healing capacity.v When homeostasis declines, homeostatic acupoints are gradually transformed from a latent phase (non-sensitive) to passive or active phase (sensitive with or without palpation). The positive systemic response to dry needling the 24 homeostatic points makes it possible not only to treat the localized injury, but also to prevent running injuries by boosting the healing and recovery response of the body. Treatment frequency varies based upon the degree of restriction or injury and overall health (self-healing potential determinant). Dry needling may be incorporated into your physical therapy exercise and manual therapy treatment to bring about more timely results and functional improvement in running performance. Call or email John Fiore at Sapphire Physical Therapy to learn more about dry needling. Feel free to call and schedule an appointment to see how dry needling can be an effective, efficient addition to your running injury prevention and treatment plan.
John Fiore, PT
Sapphire Physical Therapy

i Ma YT: Biomedical acupuncture for pain management: an integrative approach. Philadelphia, PA. Elsevier Churchill Livingstone. 2005. ii Tracey KJ: The inflammatory reflex, Nature 420:853-859, 2002. iii Wang H, it al: Nicotine acetylcholine receptor alpha7 sub-unit is an essential regulator of inflammation, Nature 420:384-388, 2003. iv Ma YT: Biomedical acupuncture for pain management: an Integrative approach. Philadelphia, PA. Elsevier Churchill Livingstone. 2005. v Dung HC: Anatomical acupuncture, San Antonio, TX, 1997, Antarctic Press.

A September 9, 2015 article in the New York Times brought to the forefront the work of Paul DeVita, a professor of kinesiology at East Carolina University in Greenville, N.C., and president of the American Society of Biomechanics. Dr. DeVita’s research compared the lower leg and ankle function of young runners in contrast to runners over forty years of age. His initial research in 2000 looked at gait changes with age at walking speeds, whereas his 2015 research data was gathered at running speeds. While the results are alarming, incorporating the study finding into your training program will greatly reduce running-related overuse injuries.

The over 40-49 age group has seen a huge increase in numbers in the past decade. As a runner who was once a member of the 40-49 age group, I have experience the changes in running performance associated with age. DeVita’s research confirmed a 20% reduction in running speed per decade beyond forty. Both running stride length and lower leg muscle function decline in a linear manner with age. Calf (gastroc-soleus muscle) and ankle dorsiflexion (tibialis anterior muscle) functional strength both decline with age. A reduction in lower leg muscle strength and function shifts the burden of self-propulsion to our hips and glutes which are already physically challenged by prolonged sitting and tight hip flexor muscles.

Lower leg, foot, and Achilles tendon injuries become increasingly common in runners over forty. Gradual degradation of muscle and tendon tissue integrity and nerve innervation sets the stage for an increase in running-related overuse injuries. On a positive note, the information provided by Dr. DeVita’s research will serve to guide strength and conditioning programs for runners interested in injury prevention and running performance. Stretching the calf and lower leg muscles, Active Release techniques, dynamic warm-up, and rolling are great ways to improve lower leg muscle tissue mobility. Lower leg, ankle, and foot strengthening exercises should be a part of every runner’s training program, not just those in the fourth decade of life and beyond. Strengthening exercises should include single leg heel raises, heel drops, resisted ankle inversion/eversion/dorsiflexion, and intrinsic foot strengthening exercises. Of course, the gluteal musculature and core are not to be forgotten as older runners rely on these inherently weak muscle groups in the absence of full lower leg and ankle strength.

If you have been battling a lower leg, ankle, foot, or Achilles injury, email me your questions to determine how you can not only return to pain-free running, but also prevent future injury recurrence. Strength and muscle/tendon tissue mobility are the keys to running faster beyond your forties!

John Fiore, PT

Sapphire Physical Therapy


Reynolds G, Why Runners Get Slower with Age. New York Times. 2015, Sept 9.
DeVita P, Hortobagyi T. Age Causes a Redistribution of Joint Torques and Power During Gait. J Appl Physiol (1985), 2000, May; 88 (5):1804-11.
DeVita P, Fellin RE, Seay JF, Ip E, Stavro N, Messier SP. The Relationship Between Age and Running Biomechanics. Med Sci Sports Exerc. 2015, Aug 7.

September marks the beginning of the fall running season. Smoke-filled skies will soon give way to clear, frost-covered mornings. While fall offers some of Missoula’s best running conditions, nine months of running miles often results in fall aches and pains. Lower extremity running injuries impact 19% to 79% of runners. Factors which lead to an increased incidence of running injury include a significant increase in running distance, terrain, or pace, a change in overall body composition or strength, and a lack of adequate recovery or rest following a workout or race.

When running-related pain develops, it is important to determine whether the pain symptom is the result of an underlying weakness and/or a mechanical problem located elsewhere in the body. The running body in motion is subjected to multidirectional forces. Our body’s ability to dissipate excess force, minimize impact force, and transfer these multidirectional forces into forward running progress determines our running efficiency. Evaluating a runner’s efficiency through video evaluation is an excellent way to determine potential injury-causing compensations to improve running efficiency.

Sapphire Physical Therapy offers video running evaluation which allows runners to watch themselves run in slow motion. A physical therapist will point out any running gait deviations and explain how such deviations may lead to or be the underlying cause of running-related pain. An August, 2015 study in the Orthopedic Journal of Physical Therapy reviewed 974 studies to determine whether or not visual feedback (in the form of video analysis, visual feedback) and verbal feedback are effective in improving running mechanics. The study confirmed that both visual feedback and verbal cues are effective in modifying running mechanics. The key to an effective and useful running video analysis lies in the ability of the physical therapist to detect running gait deviations and translate those into simple cues to be used while running. Running injury treatment and prevention simply makes more sense when pain, weakness, and running video compensation can be related to one another.

Below are several examples of simple verbal cues which may be utilized based on possible running gait compensations based on a video running evaluation. Contact John with any questions or comments and learn more about our comprehensive running and physical therapy services at

* Shorten your stride length

* Increase your running cadence

* Land with your foot beneath you

* Allow your hip to extend using your gluts

* Incorporate your big toe while pushing off

* Relax your upper body and breathe

John Fiore, PT
Sapphire Physical Therapy

Agresta C, Brown A. Gait Retraining for Injured and Healthy Runners Using Augmented Feedback: A Systematic Literature Review. J Orthop Sports Phys Ther 2015;45(8):576-585. doi:10.2519/jospt.2015.0503