Physics...Physiology...Physical Therapy

Hip and Achilles pain, where do we start?

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This week’s spotlight is on Victoria. She is a rockstar collegiate runner who has had bilateral hip pain and achilles pain. Her pain has made it difficult to train and compete over the last year. Originally, she began experiencing hip pain after performing lateral lunges. The achilles pain had a progressive onset several months later. Most of these videos are taken several weeks into treatment, so she has already made progress. Here is footage of her running.

I apologize for the video not being very close-up, but we can make it work! The biggest things that jump out to me are the hard landings/slow push-off of both feet, as well as her high and tensed arm swing on both sides. There is a little excessive hip motion side to side also.

Upon more thorough assessment, we found deficits in her hips’ external rotation, as well as limited inversion of her rearfoot(heel bone) both right and left. How do these findings translate to running form? With hip motion, as your leg swings through it is primarily going through flexion, but on a more subtle level it is also externally rotating. As the foot hits the ground, there needs to be enough margin in the flexibility to allow the muscles to load further to accept body weight onto that leg. If you’ve used up the flexion/external rotation too quickly, than the glut muscles are not able to properly accept the load, which means something further up the chain must do that. Enter the high and tensed arm swing. While running, our arms serve mostly as a way to counterbalance our lower extremities and load the core from above to allow for overall improved efficiency. This also opens up another discussion on the core that we’ll get into at a later time. In brief, think of your core as a pivot point for the body. With running, that pivot point should be relatively close to your pelvis and lower abdominal area. For Victoria, her pivot point was much higher, closer to her upper back, which is why her arms have to work so hard to give the counterbalance her lower body needs to move forward. She also has struggled with neck, shoulder, and upper back tightness for some time.

Her feet also need addressing, as the inability of her heels to invert, translates to a poor transition from loading of the foot to pushing off. In order to push off well, we need to be able to pry our heel off the ground, while the foot and calf are in a loaded position (dorsiflexed). Hopefully that makes sense, I think a more thorough video on this specific topic may be forthcoming! Anyway, here is what we did to improve the foot mechanics. Notice that she is in a traditional calf stretch position, but the focus of the exercise is to rotate the lower leg to unplant the heel, without actually lifting the heel up. In the video, I’m assisting the movement, but it can be done without help.

We also did a stretch for the posterior hip. It’s most helpful to do it in two stages, first the rotation of the hips, which is shown very briefly at the beginning, and secondly the forward trunk lean.

After these active stretches and movement exercises. We took to the pavement to work on form drills. Rather than focus on feet and lower extremity stuff, we monkeyed with her arm position to see how this affected the rest of her.

These types of drills are helpful for developing better core control while running. As discussed above, the core should be a pivot point between the upper and lower bodies. Where exactly that pivot point is can make a huge difference when it comes to running more or less efficiently, as well as with or without pain. For Victoria, her pivot point was way too high. This isn’t something that can just be consciously corrected, so a way to monkey with this is to put her arms in an extreme position. This forces her body to establish a difference pivot point, because the arms are no longer able to counterbalance as they had been. Ultimately this forces her hips to work more efficiently because they can’t pass the buck higher up the chain as they were previously.

Comparing the videos with her hands to the right and left respectively, it’s helpful to note that her hips looked more efficient with her hands to the right. This can reveal Right-Left imbalances as well, though we focused on both sides equally today.

After these drills, here is another video of her running. Again, all the running videos were taken after we had already improved hip and foot motion, so the change isn’t as dramatic, but still very important.

Notice her arms are more relaxed and there is less hip side to side motion. With continued focus on more efficiency with her transition from load to push-off, and working on core stability/mechanics as mentioned above, she will continue to make gains over the coming weeks. Great job Victoria!

Hamstrings bend my knee right?

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The hamstrings are a misunderstood group of muscles. When most people think about hamstring health, the first things that come to mind are usually stretching by touching your toes, standing or seated, or strengthening by seated hamstring curls on a weight machine. Do these stretches/exercises target the hamstrings? Absolutely. Do they teach the hamstrings how they are supposed to behave in functional movements? Hardly.

So this begs the question: what do your hamstrings do and how do we properly train them? The answer: it depends. It depends on what you do. This will look different for a runner compared to a farmer, or a soccer player compared to someone sitting in a desk all day. For the purposes of this post, we’ll keep it in the context of running. Quick anatomy lesson: the hamstrings are a group of three muscles that originate from the ischial tuberosity (sit bone) and extend past the knee, two out of the three on the inside of the knee, the other attaches to the head of the fibula on the outside of the knee.

There are three primary phases for each leg with running: 1) swing phase, 2) loading phase, and 3) push-off phase. The hamstrings have different functions during each phase and it’s important to understand what’s supposed to be happening at each. Also, most of the discussion will focus on the sagittal plane of movement (forward/backward), as this is the most obvious direction to observe. There are movements and forces in the transverse plane (rotational), and frontal plane (side to side) that we’ll touch on, but focusing on the sagittal plane will help keep details a little cleaner.

Swing phase: This is the ‘open chain’ portion of the cycle where the foot is off the ground swinging forward. During this phase the knee should bend as the hip flexes. The hamstring is not responsible for this knee bend, but rather the hip flexors driving the femur forward and momentum of the lower leg created by the push-off. The hamstrings during this phase are partially responsible for slowing down hip flexion as the swing phase ends, but are relatively quiet at the knee.

Loading phase: This is where the fun begins. As the foot touches the ground and body weight is loaded onto the planted foot, the hamstrings become more awake. At the knee, the hamstrings are mainly responsible for keeping the knee stable, not allowing terminal extension too quickly, nor allowing the knee to further flex. (The soleus is mainly responsible for controlling the knee during loading phase, but the hamstrings also assist with this.) At the hip the hamstrings eccentrically control anterior pelvic tilting, which translates to preventing trunk/pelvic flexion and ultimately keeping your upper body upright. The tricky part about this phase is that the hamstrings are responsible for both the knee and hip. As long as the knee and hip are behaving, than all is good, but if there is dysfunction in any of the adjacent joints or muscles, than this can cause a brief, unhealthy, tug-of-war which can quickly translate to a strain or pull.

Push-off phase: At the transition from loading to push-off, the hamstrings act like a catapult helping to propel the hips forward over the fixed lower leg. The hamstrings assist with extending the knee at this point to allow for full push-off. Then the leg is back into swing phase.

Again, when considering hamstring health, it’s most effective to train them in a way that translates most directly to what they need to do for the specific activity. The majority of the hamstrings’ contribution to running occurs with the foot planted on the ground. Because of this, the most effective hamstring exercises are done with the foot on the ground or planted on something, and the upper body mimicking the movements that occur during running. Here are a few examples.

First, a stretch for the hamstrings with rotational reaches to target different parts of the muscles.

Next, a strengthening progression, essentially a single leg deadlift, then hip rotations to strengthen the hip rotators.

Lastly, a variation of the single leg deadlift with theraband around the knee to challenge control in keeping the knee out of early terminal knee extension.

Give them a try or pass these on to someone who may appreciate better hamstring strength or flexibility. Let me know how you do with them!

Core strength to keep run form going

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This week’s spotlight is on Katelyn. She presented without pain or limiting factors, but reported that her running form tended to break down when fatigue set in or at the end of a 5k race. Let’s see what she looks like initially.

The biggest thing that jumps out is the extraneous movement in the hips with rotating and upper body with side to side movements. A significant forward trunk lean is also present. With running, a total body forward lean is ideal. It’s been said to lean at the ankles, which is a good way to approach it. She tends to lean forward at the waist, which is not ideal because it makes it more difficult to have proper knee drive or foot placement, notice the slight overstride also. With each stride, the shock of the ground reaction should be quickly absorbed and rebounded in the hips and lower core. Anytime extra upper body movement is observed, it’s a good bet that the core is not functioning properly.

So, we used a few approaches to fire up her core, especially in a way that mimics what the core needs to do during running. We used an 8# ball to create extra load pulling forward, this forces her to be keep her upper body more upright. This brings the glutes into the equation more and forces them to fire more quickly to keep her from falling forward.

And another version, just more dynamic, again to simulate the loading and pushing off of the normal running cycle.

And again the jumping lunges, but the ball overhead creates more vertical load as well as increased work for the hip flexors of the trailing leg, which should translate to a more efficient knee drive.

Here’s another exercise to fire up the lower abs, which will also help with knee drive. She had better reps than the video shows, but you get the idea. This exercise can be done effectively keeping the knees straight or bent.

After these exercises, here is what her form looked like.

Notice improved posture from the side view with decreased forward trunk lean and improved knee drive. The overstriding is decreased also. From the back, her upper body looks more efficient. The focus on our session was on strengthening. Just to be clear, it is not possible to make true muscle strength gains within a session like this, but what is possible is the proprioceptive gains by practicing the movements. Essentially, practicing the proper movements will dial in the neuromuscular system in a way that will translate to better muscular performance, and this can happen within a matter of minutes. The key to making it a lasting change is repetition in order to set a new default mode for the specific activity.

So, with constant practice of these exercises, this should translate into better strength and more efficiency, which will allow her to maintain her form throughout races and hard workouts. Great job Katelyn!

Medial calf pain due to slow push-off

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This week’s spotlight is on Rachel. She is a superstar runner who has battled medial upper calf pain. Here is video of her running initially.

The first thing that jumps out to me is that she demonstrates what I would describe as a shuffling gait. This is characterized by decreased knee drive and a pendulum motion of her hips and legs during swing. Ideally more knee drive would be present giving an appearance similar to her feet being on a bike. With looking at her feet more closely, the biggest issue is a lag time between when the loading phase of gait ends and the push-off phase takes over. With running, that transition should be nearly instantaneous. A huge component of running efficiency and injury prevention is how quickly can you make the transition from landing to pushing off. With Rachel, there is a lag time causing increased time with her feet on the ground, which means the muscles that are responsible for that transition are not firing adequately. This can be caused by a number of different issues throughout the feet, lower legs, hips, and/or core. But her biggest areas of weakness were in the lower legs. So this is where we focused for this session.

First, a calf stretch with inversion bias to more closely mimic not only the dorsiflexion needed at the transition point, but also the ankle inversion that is needed. For this video, we’re focusing on her right foot. It’s okay for the heel to pop up off the ground slightly for this one!

Next, an exercise for push-off through the hips and foot. It’s also okay in this one for the heel to come off the ground.

Lastly, a pure foot strengthening activity. You may have seen this one on here before. I like to call it penguin running. The idea with this one is to keep your knees and hips locked to force your feet to quickly load and push-off without any help upstairs.

We also did myofascial work for her calves to help alleviate the cranky areas before doing the exercises. This was focused primarily on her medial upper calves.

After all this, here is what she looked like running.

The improvements will definitely take time to become more obvious, but there is definite improvement with her knee drive and quickness to push off through her feet in these last videos. With continued work in these areas, she will become more efficient and get rid of the nagging pain. Great job Rachel!