Run On Softer Surfaces Or Improve Running Technique?

I read with interest two recent letters written to the Forum page in the Straits Times in the past month. One writer suggested making softer surfaces for runners at park connector paths to take care of runners' knees.

Another writer said it's not the running surface but a runner's poor running technique that causes the knee joints to wear out.

In today's Forum page, another two writers wrote in with their comments. The first writer acknowledged that both running surfaces and running technique may be the cause of knee problems. However, he thinks that excess weight may be a contributing factor too since 30 percent of 500 respondents in a survey said they had gained 5kg during the pandemic (of course there were many others who lost weight too).

The second writer, a medical doctor suggested brisk walking rather than running for joint longevity. He also said that his heathiest octogenarian patients maintain a healthy weight by being active through walking rather than pursuing 'exercise achievement goals'.

Running definitely does not wear out your knees. I've written about this before and there is so much research supporting this.

If anyone should be paranoid about running wearing out the knee joints, it should be me after 3 knee operations. The following are my personal views, backed by published articles. 

Although research has shown that there is no difference between running on the road versus grass in terms of leg inflammation, I personally feel it is much softer to run on grass or the soft sand on the beach compared to running on the pavement or road.

If you're heavier, that can put more load on the joints definitely, but running does not wear out the joints. By all means improve your running technique or do deep water running if you have to.

Be patient, increase your training load gradually, have at least one rest day a week and don't do too much too soon.

*Have a look at page A17 in today's Straits Times (270121)

Tiger Woods Blames Running For "Destroying" His Body

I came across this article from Runner's World and the video here recently saying that Tiger Woods blamed running for his decline in golf.

Tiger Woods turned pro at age 20 (in 1996) and revolutionized how golf was played. He trained really hard physically and many others copied his physical training regimen (after seeing his success) in order to catch up. He made golf really, really popular. Lots of young local golfers I treated wanted to be like him.

Many courses had to "Tiger-proof" their course by adding yardage to their tees because of his long hitting ability.

Well, with all due respect to Tiger, I don't think it's fair at all that he attributed all his injuries to running over 30 miles (or > 48 km) a week over six years.

Yes, Tiger had numerous knee surgeries after tearing his Anterior Cruciate Ligament (ACL) and at least four back operations.

I would say that his injuries were definitely partly due to his ability to hit the ball so far. The fact that he generated so much forces with his hard hitting that it affected his left knee and back.

Stand up and try this now. If you are right hand dominant, when you rotate your body to hit the ball, you can feel the rotational forces though your left knee and back. For Tiger fans, here is another possibility.

I've written before that running more miles does not wear out your knees. Plenty of published evidence support those findings. Done correctly, running is actually good for your back.

And the stress from his "personal affairs" definitely did not help either.

So don't worry, if you do not have any pre- existing injuries, running more than 30 miles (48 km) a week will not "destroy" your body or knees.

Can You Keep Running With Bad Knees?

Picture by richseow from Flickr

I often get this question from my patients. Will running wear out my knees? And my answer to them is a definite no. Not if they don't have a preexisting knee condition.

It's been proven beyond reasonable doubt that running does not wear out your knees. Numerous studies found no evidence that runners were more likely to develop knee osteoarthritis while comparing groups of runners versus non runners.

In fact, runners seem less likely to develop knee problems due to the reduced weight and the ability of articular cartilage to get stronger due to the running (Williams, 2013).

No this is without doubt good news for runners without any knee problems.

What if the runner already have a knee osteoarthritis, where the natural shock absorption between the knees have worn out? If you keep running will you hasten the progression of the osteoarthritis?

Just because running doesn't wear out your knees and/ or cause osteoarthritis, that doesn't mean you're immune to it.

Personally I think that logic suggests that if the knee joint is already compromised, it is likely that the stresses that result from running could possibly worsen the wear and tear despite little evidence on the topic so far.

Hence, this newly published study which studied almost 5,000 subjects for nearly ten years is worth a read. In that group, there were 1,203 people over 50 years old who had osteoarthritis in at least one knee. 138 of these 1,203 people happened to be runners throughout the study period.

The subjects went through many diagnostic tests, including x-rays to find out how severe their knee osteoarthritis was. These tests were repeated four years later. Those who ran during this period of time did not have a faster progression of symptoms  than those who didn't run. There was little evidence to suggest that running was harmful in this study group.

This was contrary to what the authors expected. Running was not associated with worsening knee pain nor did their x-rays showed any worsening. In fact, the authors suggested that the runners had more improvement in knee pain compared to the non runners, suggesting that there may be a benefit to running from a knee health perspective in people who have knee osteoarthritis.

While comparing x-rays for "joint space narrowing", which indicates that the bones are getting closer together because the cartilage is disappearing, 23.6 percent of the non runners got worse in the study period, compared to 19.5 percent of the runners.

39.1 percent of the non runners had improvements in the knee pain compared to 50 percent of the runners. After adjusting for age, BMI etc, the runners were 70 percent more likely to see improvement in their symptoms.

Now before all you runners and non runners with osteoarthritis get too happy and carried away and start running like there's no tomorrow, bear in mind that there isn't much information as to how much distance the runners covered or any other differences in the running versus the non running group.

Please note that the runners were not told to go forth and run as much as they wanted. They were not given any specific instructions at all about running. The runners were presumably following their own urges to run and common sense plus advice from their doctors/ physiotherapists.

There was no mention whether they ran less frequently or shorter distances than they were used to. Did they have to stop and walk if their knees started hurting while running?

I've seen many patients with reduced and compromised mobility due to an arthritic knee and hence would hesitate to suggest they start running especially if they were not already runners to begin with.

I do observe that once the patients have osteoarthritis, it generally leads to a reduction in their physical activity which may then lead to an elevated risk to other chronic conditions like heart conditions and diabetes. I would definitely suggest they remain active through stationary bike riding (for safety reasons) and of course aqua based rehabilitation/ deep water running.

This study doesn't tell us that you can run through osteoarthritis with no consequences. It does however, offer some tentative support for letting your symptoms be your guide. It doesn't mean quitting for the runner with osteoarthritis. If there is no swelling and no pain, you can probably still run. But definitely, please modify the distance, intensity and frequency that you run.

It may mean substituting a bike or swim session for the run occasionally, trying a different shoe, different surface and/ or including a weight training session to get yourself stronger. If you can still find a running routine compatible with your osteoarthritis symptoms, the results of that study should reassure you that you're not making your knees worse by running.


References

Lo GH, Musa SM et al (2018). Running Does Not Increase Symptoms Or Structural Progression In People With Knee Osteoarthritis: Data From The Osteoarthritis Initiative. Clin Rheumatol. DOI: 10.1007/s10067-018-4121-3. Epub.

Williams PT (2013). Effects Of Running And Walking On Osteoarthritis And Hip Replacement Risk. Med Sci Sp Ex. 45(7): 1292-1297. DOI: 10.1249/MSS.ob013e3182885f26.

Oh my aching knee .....

More Miles Does Not Mean Bad News For Your Knees

Singapore Stan Chart Marathon picture by RunSociety from Flickr

You will know someone who has had to rest from running because of an injury. And you will probably know someone who has been told by the doctor to quit running or their knees will wear out. Hence, it's easy to understand why so many people believe that running is not good for their knees.

I've written before that running does not wear out your knees.

I also disagreed with the author who wrote in the Straits Times (on 240516) on the above topic and I pointed out that there is no sound evidence at all that glucosamine helps with cartilage regeneration.

Here's further proof from a recently published article that didn't set out to study runners. In fact the authors that investigated this "Osteoarthritis Initiative" study had hypothesised that "a history of leisure running may increase the risk for knee knee symptoms and ROA (radiographic evidence of arthritis) even at lower levels."

Runners were grouped into low, middle and high groups if they had done at least 250, 800 or 2000 running workouts in their lifetime. All 2637 subjects in the study had high quality x-rays of their knees done and other methods of assessing knee symptoms.

Only two to five percent of the subjects described themselves as competitive runners showing that the findings are potentially more applicable to the general population compared to other studies.

Eight years after the study, subjects (56 percent female, average age of 64) were given a physical activity questionnaire. 29.5 percent indicated that they had participated in some running at some point in their lives.

The results were the exact opposite to what the researchers expected. This "forced" them to conclude that "A history of leisure running is not associated with increased odds of prevalent knee pain, ROA, or SOA (symptoms of arthritis). In fact, for knee pain, there was a dose-dependent inverse association with runners."

This meant that the people who ran the most had the least knee pain. This was true across all age groups and for running at any stage in one's life. The subjects that were still running had less knee pain (21.1 percent) than those who had quit running (25.3 percent), who had less pan than those who had never ran (29.6 percent).

So, most recent medical research continues to "exonerate" running as a cause of knee osteoarthrits. You now have more "ammunition" to show the naysayers who tell you to stop running or your knees will wear out.

Reference

Lo GH, Driban JB et al (2016). History Of Running With Higher Risk Of Sympyomatic Knee Osteoarthritis: A Cross-sectional Study From The Osteoarthritis Initiative. Arthritis Care and Research. DOI: 10.1002/act.22939.

A Running And Glucosamine Article I Do Not Agree With

ST 240516

"The point of journalism is to tell the truth. It is not to improve society. There are facts and truths that feel regressive, but that doesn't matter. The point of journalism isn't to make everything better; it's to give people accurate information about how things are." Sebastian Junger.

I've never started an article with a quote before, but the above quote caught my eye and I feel it is only fair to give our patients and readers accurate information about how things are (even though I'm not a journalist. Don't get me wrong I'm not blaming the writer, I just want to present an evidence based view.

Not another running bashing article - that was my first thoughts glancing through the papers today "When running wears out the knees (ST 240516). This is under DocTalk on page B10.

I totally did not agree with the author on that. There is more than sufficient evidence to show that running does not wear out your knees.

The author's article also quoted studies saying that 35 percent of patients taking a regular dose  of 1500 mg of glucosamine sulphate daily can increase cartilage regeneration.

May I kindly draw your attention to a Cochrane review where authors showed that glucosamine was generally safe to ingest but does not help with pain. I've written about glucosamine back in 2010 and 2009. Go and have read if you're keen.


Reference

Townheed T, Maxwell L et al (2008). Glucosamine Therapy For Treating Osteoarthritis. Cochrane Database of Systematic Reviews. DOI: 10.1002/14651858.CDOO2946.pub2.

Running Does Not Wear Out Your Knees

Picture by Cameron Drake on work done by Dr Noah Weiss

How many of you have had friends tell you that you'd better stop running as running causes your knee joints to wear out. I've had my fair share too.

Well, now you can tell all the naysayers that running (at any age) does not increase your risk of osteoarthritis (or wearing out of your joints), in fact they may even prevent the condition. This information was presented at the annual meeting of the American College of Rheumatology.

Researchers did a long term study on 2,683 subjects at four stages of their life : 12-18, 19-34, 35-49 and 50 and older. They were classified as a runner at that stage if they listed running as one of their three main activities.

X-rays of the knees were collected as well as subjects' reports of symptomatic pain. The knee x-rays were repeated again two years later. Analyses showed that 22.8 % of the participants who were runners had need osteoarthritis compared to 29.8 % who had never been a runner. And get this, average age of the participants was 64.7 years.

The authors concluded that "non-elite running at any time in life does not appear detrimental and may be protective" in regards to developing knee osteoarthritis.

Reference

http://acrannualmeeting.org/wp-content/uploads/2015/02/2014-ACR_ARHP-Annual-Meeting-Abstract-Supplement.pdf.

Glucosamine, Chondroitin & MSM

I've had many of my patients ask me if they need to be taking any supplements. Some even tell me they swear by their daily glucosamine and chondroitin pills -the 2 supplements favored by most runners. My patients were all really convinced the supplements worked until I tell them the published evidence.

In some earlier studies, there seemed to be some evidence supporting the use of glucosamine (but not chondroitin, or MSM etc). Yes, that means you do not need anything else in your tablet or pill except glucosamine. But most if not all of those studies were sponsored by the companies who made the tablets.

Based on recent studies however, researchers looked the effects of glucosamine and/ or chondroitin on joint spaces in the knees of 572 subjects with known (x-ray evidence) osteoarthritis in their knees. At the end of the 2 year follow up, there were essentially no differences between the subjects who received a placebo (or dummy) tablet and those who received glucosamine and/ or chondroitin. It was a double blinded study, meaning both researchers and subjects didn't know who were getting the dummy tablets and who were getting the real deal.

So what's my take on this. For all those who are currently taking them and feel that they work, please carry on. If not you may feel uneasy stopping anyway. For those who are thinking of starting, well, you have the evidence before you.

Have a look at much stronger evidence not to take glucosamine here.


Reference

Sawitzke AD, Shi H, Finco MF et al (2009). The Effect of Glocosamine and/ or Chondroitin Sulphate on the Progression of Knee Osteoarthritis. International Society of Sports Nutrition.