The dietary supplement industry is a $30 billion per year behemoth, and athletes of all levels are major consumers. Unfortunately, much of the product sold is worthless at best - and may even be harmful! - but not all supplements are snake oil. For an athlete interested in utilizing supplements to support their health and active lifestyle, it can be a daunting task to sift through this landscape. Admittedly, even many physicians are ill-informed when it comes to supplements. Even worse, perhaps, they are actively engaged in selling expensive lines of questionable products that instill an inherent bias in their recommendation. It can get messy!
In this article, I’ll give you my thoughts on dietary supplementation and how to determine which supplements may be right for you. As a transparent statement of my potential conflict, we sell a line of supplements at Podium. Thorne Research makes incredibly high quality products, but more importantly many are tested and certified to be free of banned substances. Twelve US Olympic programs use Thorne as their sole provider of supplements. I have many athletes in my practice who are routinely drug-tested, and I feel confident in Thorne’s guarantee of quality and purity. There are other great brands on the market, and fortunately Knoxville has an amazing resource for advice and supply in Eddie’s Health Shoppe! I send many patients to Eddie Reymond and can recommend him and his shop without hesitation. And now, on with the article…
Before we delve into the details of supplementation, the very nomenclature must be addressed. These substances, if used at all, should be supplemental to a healthy diet. You cannot eat poorly, take a daily multi-vitamin, and expect everything to be okay. The most important component of your dietary health is your diet! Whole, nutrient-rich foods must be the cornerstone of your regimen. If you are found to be in need of extra magnesium, ensure you are eating healthy amounts of spinach, pumpkin seeds, almonds, and other real foods. You are unlikely to fix the problem by adding a magnesium tablet to your cheeseburger diet.
Should you determine that dietary supplements may be helpful for you, the next concern is one of quality. A federal act passed in 1994 exempted supplement manufacturers from FDA oversight. This created a potentially dangerous scenario for consumers. In 2015, the state of New York tested “top selling” vitamins and supplements at GNC, Walgreens, Target, and Walmart. The results were appalling. Most of these supplements contained only powdered rice, fillers, and other inactive ingredients, like “house plants”. There was little, if any, of the substance the customer thought they were purchasing.
Given this background, an athlete’s first task is to ensure they are buying from a brand that takes their product seriously and utilizes good practice in their manufacturing. I would never recommend choosing a product blindly off a store shelf. Discuss specific products with someone knowledgeable on the topic.
Once that hurdle is cleared and you have a resource for quality dietary supplements, the next step is to determine which might be useful for you. This could be a very long conversation! A well-informed sports medicine physician or dietician should be consulted. I think athletes should undergo simple blood tests to determine whether they are in need of extra iron, magnesium, Vitamin D, or other nutrients. There is no reason to guess at the dosing. Work with your doctor to set up the appropriate panel of tests to help guide your diet and supplementation.
For athletes, there are some supplements that can be nearly universally helpful. Others should only be taken when insufficient levels are demonstrated through testing.
Multi-vitamin - It seems like practitioners are either adamantly for or against a daily multi-vitamin. To me, it’s an often misguided argument. Many doctors cite studies with irrelevant end-points. Do you care whether a group of 65-85 year old men with a history of heart attack lived longer when taking a multi-vitamin for 18 months? Unless you fall into that narrow category, the answer is probably “no”. Yet these types of studies are often used as rationale for multi-vitamins being worthless or unnecessary. As I see it, athletes have a very high nutrient demand. A good diet is paramount! But a high-quality multi-vitamin designed for athletic needs can play a very important role. The goal may not be increased longevity. Instead, ensuring adequate intake in the setting of high nutrient turnover could help with energy, vitality, and resilience in the face of a heavy load of training and racing.
Fish Oil - Omega 3 fats are beneficial to many athletes. They can balance Omega 3:6 ratios, help maintain healthy lipid profiles, decrease inflammation, and even combat muscle soreness after a workout.
Protein - An athlete requires between 1 and 2 grams of protein per kilogram of body weight per day, depending on their training goals. For many, this can be rounded to 1.5g/kg/day. That is a fairly large dose of protein. While dietary proteins are certainly best, many athletes can benefit from occasional protein supplementation to aid in maintaining or building muscle mass and supporting recovery from workouts. Additionally, certain amino acids like Glutamine can further aid this process.
Should Be Dosed Based on Blood Tests
Iron - An essential component in the transportation and utilization of oxygen as aerobic fuel, iron can be a “make or break” nutrient for endurance athletes. However, too much can cause health risks. An easy blood test can tell you whether you should increase your iron intake.
Vitamin D - This has certainly been a trendy vitamin over the past decade, and often with questionable evidence at best. However, we know that an individual’s level of Vitamin D impacts their muscular function, recovery, hormone formation, and immune status. While very high levels are not desired, we do see that athletes with high training loads and/or certain ethnic heritages are often low in this crucial nutrient. Again, a blood test can easily tell you if you need to add supplemental intake.
Magnesium - This mineral is abundant in the body, but there is a remarkable degree of insufficiency in athletes. Studies have shown that adequate levels of magnesium can decrease blood pressure, improve insulin sensitivity, possibly improve aerobic performance, and improve sleep – all beneficial to athletes.
Other supplements may also be situationally useful, but anything strong enough to have a positive effect may have a negative effect in the wrong setting. Vitamin C acts as an antioxidant, boosts immune function, and may even play a role in the healing of soft tissue injuries; however, larger daily doses have been shown to slow the rate at which athletes increase their fitness in response to training. Context is key, and working with a knowledgeable practitioner makes all the difference.
At the end of the day, high-quality supplements can be an important part of an athlete’s training and dietary regimen, but they should be considered as potent substances with the potential to help or harm, depending on context and individual need. Athletes should consult with their physician before starting a supplement regimen. For many, simple blood tests can guide dosing and determine need. Some supplements can have dangerous side effects or interact with medications, and some products can actually be detrimental to health and performance if taken inappropriately. Work with your doctor or a qualified nutrition expert to determine if supplementation could benefit you.
Many runners have been prescribed orthotics at some point in their running career. This may be as simple as a suggestion for an off-the-shelf “supportive” insert, or as intricate as a custom device made specifically for the foot of an individual. As a runner, you are probably familiar with orthotics. If not, they are basically supportive insoles designed to change the mechanics of the foot, ankle, knee, and hip when running or walking. The prescription of orthotics usually comes from a physician, podiatrist, or physical therapist, some of whom make their own for patients.
While commonplace in the treatment of running-related injuries 10-15 years ago, orthotics have become a bit of a relic today, and for good reason. As our understanding of running mechanics and injury has progressed, we’ve learned that, in most cases, orthotics did not do patients any favors. Let’s take a closer look and the evolution of “best practice” as the evidence has been gathered.
Before going to medical school, I worked in a running shop. My undergraduate research focused on rear foot motion in runners, so I had a particular interest in this topic. We spent time fitting runners to shoes based on their arch height and sometimes even watching them run briefly on a treadmill. The cutting-edge knowledge of the day told us that runners with a lower arch and over-pronation of their heel would require a very supportive, “motion control” shoe. Those with higher arches and less pronation (or even supination) should be placed in a cushioned shoe. Matching the foot and the foot mechanics to the right shoe would control the movement of the foot, which would correct the mechanics of the ankle, knee, and hip. If we could get them in the right shoe, and perhaps the right insole or orthotic, we could help them alleviate their pain. Of course, this is a bit oversimplified, but I’m sure some of this will sound familiar to many readers.
Most problematic was the runner with a low arch and excessive pronation in their gait. We thought that a supportive, even custom, orthotic would hold the foot in the proper position through the stride and allow the rest of the leg to function optimally. It makes sense at first, but it’s just not that simple. As this theory was tested in study after study, it didn’t hold up. At best we got mixed results, and mixed results are about as reliable as a coin flip. So sports medicine had to go back to the drawing board.
The question we should have been asking was, “Why does this runner’s foot have this shape, and why does it move the way it does?”. As with most things in medicine, a forced fix was not the answer.
The barefoot running movement ushered in a new way of thinking about gait and biomechanics. Admittedly, there were many problems with barefoot running and its implementation on a broad scale, but that was the pendulum swinging. We’re starting to see it settle back in the middle, having learned lessons from both extremes. Barefoot running taught us the importance of learning to run correctly. Proper form can be neither forced nor assumed, but it can be taught.
So, where do we stand now? What have we learned about orthotics for runners? Here’s a useful analogy I often share with patients. If you were to come to my office with a broken ankle, we would put you in a cast. But that’s not the fix! We don’t just cast your ankle, throw up our hands, and “voila!” you’re better! The cast serves the short-term purpose of helping you through an injury, and then it is removed. Orthotics should be considered in the same light. If your degree of pain and injury is such that you are unable to move well and cannot even complete rehabilitative exercises, an orthotic can be a great short-term aid to help you through the healing process. However, I still see patients who have been prescribed orthotics and are wearing them years later! In 99% of cases, that is unwarranted and a sign of very poor treatment, in my opinion. Often, the reason I see them in my office, is that they are now having different pains when running. The orthotic may have altered their foot and ankle mechanics, but no one fixed the underlying problem. The imbalance and weakness persists, poor movement is still their norm, but the stress has shifted to a different body part.
Instead of asking how we can restrict movement at the foot and ankle, I think we should be looking at runners to see how we can fix the movement dysfunction and help them attain a strong, resilient gait pattern. Placing a runner in an orthotic is not a treatment success. Instead, the goal should be to transition patients out of their orthotics to pain-free running with improved mechanics. Sports Medicine literature demonstrates that orthotics are, in rare cases, an appropriate short-term aid. In extremely rare cases of actual anatomic deformity, they can be a long-term necessity. Both of these scenarios should be the uncommon exception to the rule, but there are still practices that put most of their runners into orthotics. The vast majority of their use is unwarranted, likely counterproductive in the long-term, and often quite expensive.
That last point is an important one and a reason that I think some practitioners stick to an outdated treatment. Orthotics are a money maker! I don’t believe that these folks consciously prescribe a treatment they know to be ineffective. Rather, I think there is an unconscious bias toward a profitable treatment which they’ve used for years. In medicine, the evolution of care often requires us to admit that we may not have provided the best treatment to our patients in the past. That’s hard to do, but it’s essential that we remain open to new evidence and knowledge.
Rather than holding strong to an outdated or ineffective treatment, runners should take stake in their care and seek out a professional who can help them address the underlying problem. Your practitioner should watch you move, identify the dysfunction, and have a plan for you to address it in a manner which encourages you to improves your gait. Occasionally, orthotics play a short-term role, but the goal should be to work with that practitioner to get you out of them as quickly as possible. Your body is designed to move well. When that’s not happening, the addition of a rigid support is not the answer. Take the time to address the true problem, and you’ll be able to enjoy many years of pain-free running.
There are many reasons why runners should engage in both strength training and speed work, but there are even more excuses why they don’t. This is certainly changing, but momentum is slow. Published numbers suggest that nearly 70% of runners sustain an injury every year. It is my belief this incidence is not due to some inherent aspect of running. Rather it is caused by overload from certain movement patterns and from training regimens that wear down an athlete hormonally and neurologically. Running injuries are common, but preventable.
With the advent, and perhaps passing, of the barefoot/minimalist running trend came research into gait patterns and injury reduction. The initial thought was that a midfoot or forefoot strike would decrease injury rates in most people. Further studies suggested that, like most things in medicine, the answer is much more individual. Without getting into the minutia, a forefoot or midfoot gait generally decreases the forces at the knee and hip. However, a heel striking gait will decrease forces at the ankle, so your ideal therapeutic gait alteration may depend on your injury. And there is much more to the mechanics than that! You cannot discount the position of the lower leg, thigh, hip, and pelvis throughout the gait. Much of the motion we see originates in the body’s core (pelvis, hips, abdominals, and the incredibly important “posterior chain” muscles that run down the back from the shoulder blades to the knees).
Much of the pain runners encounter is given a vague diagnosis with little research or clinical evidence to back it up. However, there is interesting work being done to evaluate movement patterns (gait analysis) and treat accordingly. Dr. Andy Franklyn-Miller at the Sports Surgery Clinic in Dublin has led the way and had some fantastic success. He has coined a new term for these categories of injuries, recognizing that they are more of an aberrancy in movement as opposed to a problematic physiologic process. This “Biomechanical Overload Syndrome” is treated with correction of movement patterns, altering the force distribution and remedying the overload. Voila! No pain! Well, it’s not that simple.
What does all this have to do with strength training? Well, strength training is one of the best ways to address the movement patterns that lead to Biomechanical Overload Syndrome. Runners generally operate in a single plane of movement known as the “sagital” plane, from front to back. This continuous activity in a single direction leads to relative weaknesses in lateral movement and stabilization. When you are strong in one plane and weak in another, you create imbalances, which predispose you to injury. Imbalanced strength at the hip, for example, may cause the knee to move across the midline during your stride, setting you up for IT Band Compression Syndrome. Correcting these strength imbalances can aid in preventing or treating the problem.
Strength training can also be very beneficial to running performance, regardless of the distance. A powerful runner is a faster, more resilient runner. Body-weight exercises such as single-leg squats and lunges can help strengthen the posterior chain. Whether your preferred distance is 5K or the marathon, added strength (not muscular bulk!) will help you outperform your competition.
Another way to increase power and velocity is the proper use of speed work in training. “Speed work” has different meanings, but I intend this to encompass any training at speeds above your race-pace. My patients have likely tired of hearing this, but the only way to run faster is to run faster. You will not get appreciably faster by adding distance. You have to utilize intensity in your training. There are some important considerations. First, you need a strong core and appropriate gait mechanics when undertaking an intense training program. Should you attempt to further stress an improper gait and imbalanced body, you will get injured. How many times have you scoffed when a magazine or ad instructs you to “talk to your doctor before beginning an exercise program”? Well, this is a scenario where it probably does behoove you to talk to your sports medicine physician, review your injury history, undergo movement screening/gait analysis, and discuss an appropriate implementation of intensity. Then you can safely start to add speed to your training and racing.
As an added benefit, if not a primary one, the addition of high intensity training has very beneficial effects on your body hormonally and neurologically. Continued long, slow training causes prolonged moderate stress and over-activation of your parasympathetic nervous system. This can lead to fatigue, depression, weight gain, and diminishing performance (on the track, in everyday life, and even in bed!). The remedy is speed work and strength training.
So it all comes full circle. Strength training will make you faster and less prone to injury. It will allow you to tolerate higher intensity and the addition of speed work to your training regimen. This intensity will make you faster, more resilient, and generally healthier, but it can cause injury if imposed on a weak body. The successful implementation of these principles is very individual. Your physician will be happy to walk you through the process and insure you enjoy a fast, healthy race season.
Dr. Sprouse joined Steve Kashul and Dr. Brian Cole today to discuss athlete monitoring and pertinent training metrics. Listen to the interview on THEIR WEBSITE (when posted), or you can hear it ahead of time by clicking below.