Issue 4

Tiger Physical Therapy

June 2015

Therapeutic Solutions Quarterly

Flat Feet and Running Injury
INSIDE THIS ISSUE:

By: Richard L Cahanin P.T., D.P.T., Ph.D. (c)

Flat Feet and Running Injury:
1, 2, 5
Are Artificial Sweeteners
Beneficial?
About Authors

1, 3, 4, 6
7

Some people would argue

that running is not only a healthy
activity, but that it was an integral
evolutionary factor. Mr. McDowell
purports this theory in his book
entitled, Born to Run. In a recent
TED talk Mr. McDowell discussed the
rationale behind his beliefs.
Basically the point was that early
humans were able to run down
animals for food. Although early
humans were not as quick or agile as
deer or antelope, they had the
ability to regulate body temperature
better; therefore they had better
stamina and could run longer
distances. Once the deer or
antelope had to stop and cool down,
humans were able to move in for the
kill. As more protein became

available, humans were able to develop

faster and evolve into what we are
today. McDowells theory seems
plausible considering some of the
amazing running performances by
humans. According to a publication in
2011 entitled, 5 Most Amazing
Marathon Feats, a man completed the
Toronto Waterfront Marathon at the
age of 100. The same article stated a 49
year old man ran 365 marathons in a
year, thats a marathon a day!
Contd. page 2

Are Artificial Sweeteners Beneficial?

By: Michael Sandoz, MS, RD, LDN

As a practicing Registered
Dietitian, I often get asked, What is
the best artificial sweetener to use?
Other common questions include, Are
they safe and will they cause me to
gain weight?
Contd. page 3

Page 2

Therapeutic Solutions Quarterl y

Flat Feet and Running Injury

it is
difficult to
claim that
individuals
with pronated
feet are more at
risk for all
types of
running
injuries

Despite the record of amazing

running feats, many people sustain
running injuries. According to a review
article by Van Gent et. al. in 2007, the
annual incidence of running injuries
spans from 20-92%, depending on the
population. Not only is the incidence of
injury high, but the overall prevalence of
running injuries may be increasing
exponentially. According to a study by
the National Sporting Goods Association,
the number of U.S. marathon finishers
has increased greater than 40% over the
past decade.
Running injuries are mostly due
to repetitive overuse, so logically we
first analyze biomechanics to identify an
abnormality. Many point the finger at
their flat feet (a.k.a. a pronated foot
posture), particularly for foot injuries. If
you have a pronated foot posture, the
arches on the medial or inner parts of
your feet are relatively low. Also, a
pronated foot tends to display rear-foot
abduction, that is the heel bone tends to
angulate and weight is placed more
along the inside of the heel relative to
the outside. Moreover, while looking
from the rear, you will be able to see
more toes on a pronated foot relative to
a neutral or supinated foot.
The theory is that people with
pronated feet are more likely to get
injured because forces imparted upon
the foot are unbalanced and causes
excessive tension to soft-tissue
structures on the inside of the foot, such

as the tibialis posterior tendon.

Although individuals with
pronated feet may be more at risk for
certain types of injuries, it is difficult to
claim that individuals with pronated feet
are more at risk for all types of running
injuries compared to individuals with other
foot posture types. Esterman and Pilotto
found no differences in injuries between
low-arched, mid-arched, and high-arched
military recruits after 10-weeks of basic
training.
Contrary to popular belief, some
evidence suggests that individuals with a
supinated foot posture are more at risk for
injury. Hesar et. al. found individuals with
a less pronated foot strike were more
likely to sustain an overuse injury to the
lower limb over a 10- week start-to-run
program. Also, Neilson et. al. found that
individuals who pronated had fewer
injuries per 1000 km. of running compared
to those with a neutral foot motion.
Although some evidence indicates
that pronators are at lower risk for injury,
we should not assume that excessive
pronation is not a risk factor for running
injury. A recent systematic review with
meta-analysis by Neal et. al. found that
pronated foot posture was a significant
risk factor for medial tibial stress
syndrome and patellofemoral pain;
however the effect size was small, which
indicates that a pronated foot posture may
only play as small role in the development
of a running injury.
Contd. page 5

Therapeutic Solutions Quarterl y

Page 3

Are Artificial Sweeteners Beneficial?

In this article, I will clarify
misconceptions of artificial sweeteners,
also known as, low calorie sweeteners
or non-nutritive sweeteners (NNS).
Sweeteners that provide
calories and carbohydrates are
considered nutritive. Examples include
sugar, honey, and sugar alcohols.
Alternatively, NNS are high intensity
sweeteners that provide essentially
zero calories and zero carbohydrates.
They are described as intense
sweeteners because they are several
hundred to several thousand times
sweeter than table sugar. Insignificant
amounts are needed to provide the
level of sweetness comparable to sugar.
NNS are found in food products such as
yogurts, snack bars, sugar free jelly,
canned foods, diet or zero calorie
beverages, and are also sold
individually. Popular types include
sucralose (Splenda), aspartame (Equal
or NutraSweet), saccharin (SweetN
Low), stevia, and acesulfame potassium
or Ace-K.
Are they safe?
NNS are regulated by the FDA
under the 1958 Food Additives
Amendment part of the Federal Food,
Drug, and Cosmetic Act. Food additives
such as NNS must be determined safe
for all populations including pregnant
women and children before being
marketed. They are determined safe by
the scientific evidence presented.

Fortunately for consumers, qualified

experts, chemists, toxicologists evaluate
all relevant data to make determinations
on food additive safety that the lay
public is not equipped to determine.
There are many misconceptions in
nutrition regarding government
regulatory bodies and their motivation.
These agencies are pertinent to the
safety of our food supply. With no
review of data by qualified experts, you
have the potential of consumers making
their own decisions regarding safety and
dosages, which can have negative
consequences. This is a problem in the
supplement industry, where products
are poorly regulated.
Currently, there are seven NNS
approved for use in the United States
(U.S). Food additives have an
established Acceptable Daily Intake (ADI)
expressed in milligrams per kilogram of
bodyweight, which is the amount an
individual can consume everyday over
their lifetime without causing any
adverse effects. Not only is reaching the
ADI of a NNS unlikely, but there is also a
100-fold factor built in. The ADI for
aspartame is 50mg/kg. To put this in
perspective, an adult weighing 150
pounds would have to consume 17, 12oz diet or zero calorie beverages
sweetened with aspartame to reach the
ADI. Keep in mind; this is with a 100-fold
safety factor included. Notably, the ADIs
for saccharin and sucralose are much
lower at 5mg/kg.
Contd. on page 4

Food additives
such as NNS
must be
determined safe
for all
populations

Therapeutic Solutions Quarterl y

Page 4

Are Artificial Sweeteners Beneficial?

Recent research indicates that there are
over 6000 products containing NNS. A
review in 2006 regarding NNS
consumption patterns indicated that
average daily intake by adults was well
below the ADI.

there is no
established link
between NNS
and cancer...

Based on the current research

available, there is no established link
between NNS and cancer in humans.
None are listed as carcinogens or possible
carcinogens by the International Agency
for Research on Cancer (IARC) or the U.S.
National Toxicology program (NTP).
Saccharins safety is frequently
questioned due to a study in 1978 linking
it to bladder cancer in male rats.
However, after further investigation with
additional studies, it was determined that
the mechanism in which male rats were
developing bladder cancer was not
relevant to humans. It should be noted
that saccharin is rarely used as an additive
in low calorie products or beverages
anymore. The American Cancer Institute
states, There is no clear evidence that
artificial sweeteners available
commercially in the U.S. are associated
with cancer risk in humans. Position
statements by both the American
Diabetes Association (ADA) and Academy
of Nutrition and Dietetics (AND) indicate
that NNS can be safely consumed within
their established ADI.
There is a concern that the use of
food or beverages containing NNS causing
weight gain. However, an extensive
review regarding NNS and caloric intake
found that substitution of NNS for a sugar
sweetened food or beverage actually can
result in a reduction of total energy
intake, which can help achieve or

sweetened food or beverage actually can

result in a reduction of total energy intake,
which can help achieve or maintain a
healthy body weight. To lose weight,
calories burned, must exceed calories
consumed. Replacing a 140-calorie sugar
sweetened soda with diet or zero calorie
soda can help create this deficit. However,
NNS are not a useful tool if an individual
overcompensates for the caloric deficit they
have just created, that is eating more food
because they are now drinking diet sodas.
A joint paper by the ADA and American
Heart Association (AHA) using available
food and beverage intake data in the U.S.
showed exactly this. They found that the
current U.S. population is not directly
substituting products using NNS for
products containing added sugar even
though NNS product availability has
increased.
Do NNS increase appetite and cause weight
gain?
Mattes and Popkin investigated
eight potential mechanisms in which NNS
could increase appetite, hunger, or energy
intake. They concluded that the available
evidence refuted or was insufficient to
refute or support the eight potential ways
that NNS would promote weight gain. For
clarification, the idea that consuming NNS
increases appetite and hunger causing
increased intake has not been scientifically
validated.
Contd page 6

Therapeutic Solutions Quarterl y

Page 5

Flat Feet and Running Injury

The truth of the matter is that
static foot posture is only one of many risk
factors for running injury. Other variables
such as body weight, running experience,
foot striking pattern, activity level, faulty
joint mechanics, muscle strength, motor
control, soft-tissue extensibility, past
history of running injury, gender, age,
genetics, and running form have all been
identified as risk factors for running injury.
In addition, there are probably more
variables associated with running injury
that are either not significant contributors
or have not been identified yet. One such
variable is leg-length inequality, which I
am currently investigating.
It is important to understand that
it is unlikely that there is a single risk
factor for running injury. Chances are
that a multitude of risk factors only in
combination can predict a running injury.
For example, an inexperienced runner
with decreased quadriceps muscle
strength and faulty running form may be
more likely to sustain a running injury
than a more experienced runner with
good form and good muscle strength. In
addition, different variables may be risk
factors for certain injuries, but not for
others. For example, excessive foot
pronation may be a risk factor for
patellofemoral pain syndrome, but not for
plantar fasciopathy.
High quality studies are needed to
identify the most important variables for
running injury, the combination of these
variables that predicts injury the best, and
which conditions these predictor variables

predict. Although the research is lacking,

there are definitely things that can be done
to reduce your risk of injury; strengthening
the muscles of the legs is one thing. In my
opinion, muscle strength, activity level, and
motor control make up the top 3; all of
which are modifiable, unlike gender, age, or
genetics.
If after reading all of this you
believe you cant run because you have flat
feet, maybe an anecdote will help. I
personally know a guy with feet as flat as a
pancake that has competed in ultramarathon races. If I recall correctly he
finished a 100 mile race in about 29 hours.
That said he was in incredible physical
condition so dont think you can just crawl
off the couch and run an ultra-marathon. It
takes years of training and conditioning to
develop the skill, physical capability, and
mental toughness to be able to push your
body to such an extreme level.
So all you flat footed people out
there can relax. Just because you have flat
feet does not mean you are disabled and
cant run. You can still run or even
compete in marathon races if you wish to
do so. Keep in mind your individual
situation and be smart. If you feel you are
a high risk for injury or you have a health
condition, you should consult your
physician or a physical therapist before
beginning an exercise regimen.
A start-to-run program is now
available at Tiger Physical Therapy. Call
Richie at 985-626-5428 for more
information.

just because
you have flat feet
does not mean
you are
disabled

Page 6

Therapeutic Solutions Quarterl y

Are Artificial Sweeteners Beneficial?

Glycemic control is important in
the management of diabetes. Foods
containing carbohydrates must be
consumed in moderate portions in an
individualized meal plan to control blood
sugar and prevent complications of
prolonged hyperglycemia. According to
the Mayo Clinic, complications include,
nerve damage, blood vessel damage,
kidney damage and cardiovascular disease.
NNS can be a useful tool for preventing
hyperglycemia in people with diabetes
because they alone do not raise blood
sugar. However, some foods containing
NNS can raise blood sugar. This is due to
the sugar or starch content of other
ingredients in the product.
Do I recommend NNS?
Like most questions regarding
nutrition, that depends. I do not
recommend individuals seek out products
using NNS and add them to their diet. I
would much rather their diet be focused
around fruit, vegetables, whole grains,
lean protein, and healthy fats. If an
overweight adult male who drinks one 20oz bottle of sugar sweetened soda per day
asks me what I recommend regarding him
staying with his regular soda or switching
to diet soda, I would initially recommend
he go with water or unsweetened tea.
However, if he is not willing to make that
type of change then yes, I would
recommend he replace the sugar
sweetened with a diet or zero calorie
version that uses a NNS. This swap could
help decrease total caloric intake and be
one modification to his current diet to help
him achieve a normal body weight.
In summary, NNS are safe at
determined ADIs and are useful

In summary, NNS are safe at

determined ADIs and are useful
alternatives to sugar sweetened
beverages and food products. There is
one exception. Individuals with the
inherited disorder phenylketonuria (PKU)
should not consume aspartame due to
their inability to breakdown the amino
acid phenylalanine. Like everything in
nutrition, moderation is key. I do not
recommend excess consumption of any
type of food or ingredient. The same
goes for NNS and products containing
them.

NNS can be a
useful tool for
preventing
hyperglycemia

Therapeutic Solutions Quarterl y

Page 7

About the Authors

Mike is a Registered Dietitian (RD)
who resides in New Orleans, LA. In 2012,
he graduated with a B.S. in Nutritional
Sciences from LSU. He recently completed
his Dietetic Internship and earned his
Master's degree in Exercise and Nutrition
Science at Lipscomb University in Nashville,
TN. Mike believes that eating a variety of
foods and incorporating regular physical
activity is essential to a healthy lifestyle. In
his free time he enjoys cooking, trying new
types of cuisine, and being active outdoors.
He can be reached via email:
mike.james.sandoz@gmail.com or by
phone: (504) 512-1232. Follow him on
Twitter @MJS_Nutrition and on Facebook
at www.facebook.com/mjsnutrition.

Earn Your
Stripes!

985-626-5428

23052 Hwy. 1088

Mandeville, LA
70448

Tigerpt.com

Richard is the owner and sole

proprietor of Tiger Physical Therapy. He
received his Doctorate of Physical
Therapy in 2010 from the University of
South Alabama and is currently pursuing
a Philosopher of Orthopedic and Sports
Science from Rocky Mountain University
of Health Professions.
Richard has dedicated himself to
the art and science of physical
rehabilitation, strength training, and
physical conditioning. When not
working with patients, studying, or
researching, Richard enjoys living a
healthy lifestyle and enjoying the great
outdoors.