Physics...Physiology...Physical Therapy

Medial knee pain due to ankle restriction

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This week’s rock star is Jack. He has done a marathon in the past and is returning from a running hiatus to dominate a half marathon in a few months. Overall his training is going well without significant concerns, but he does have intermittent right medial knee pain. Let’s see what jumps out during video of him running before we start monkeying with anything.

The area that jumps out to me most is his feet, more specifically his right forefoot. What I notice is a slight apprehension to load onto his right forefoot and thus little push-off on the right side. It’s subtle, and more noticeable from behind. He also demonstrates a moderate overstride, as viewed from the side with his foot strike occurring in front of an imaginary vertical line from his hip to the ground.

After running, he performed single leg squats also as an assessment for stability.

Anytime a single leg squat is performed (which is essentially happening briefly with each stride that you take!), there should be a natural pronation of the foot, slight inward motion of the knee (valgus), as well as slight hip lateral translation (adduction). Neither leg is perfect, but what I notice in this video is how much wobble there is in his right forefoot at the transition point from loading to pushing off. This creates increased values forces at the knee which I believe is causing his intermittent knee pain. While running, this will create an instability that most people will find a way to avoid. In Jack’s case, he avoids pushing off.

As our session progressed, he mentioned having multiple ankle sprains on the right side as well as the feeling of instability. We looked at it closer and found limited ankle inversion, which will limit push-off, as well as make him more susceptible to rolling that ankle. Ankle inversion is needed as part of the push-off process, if it’s lacking than it’s more easy for an ‘inversion sprain’ to occur, which is the most common way to roll an ankle.

So, here’s what we did about it. First, an exercise to gain ankle motion.

Next, an isolated foot/ankle stability exercise on a half-roller.

Next a global stability exercise again to encourage stability with rotational motions.

And lastly, a drill I like to call ‘penguin running’ to amp up forefoot strength and control.

Again, notice how his right foot doesn’t seem to be able to point inward as easily as the left foot. This is another sign of limited ankle motion.

For a couple running drills, he simply ran on his toes to build up forefoot strength, and ran with high knees to encourage a more powerful push-off.

After all this, we turned him loose again.

Notice less of an overstride, viewed from the side, as his foot is landing more underneath his hip. His foot mechanics also are improved, as his push-off looks more symmetrical. Not hugely dramatic changes, but I expect that he will steadily improve in these areas which will translate to greater efficiency with running and less likelihood that he will have ankle injuries. Great job Jack!

Hip extension: is it due to hip flexor tightness?

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This week’s spotlight is on Kaylie. She is a collegiate runner and softball player. A real common combination right? Only a superstar could pull it off. She presented with history of hip and knee issues without significant injury, but also wondering if being in a catcher’s stance was affecting her running gait. Her coach has been working with her on improving her hip extension, mostly with stretching the hip flexors and strengthening her hip extensors. Indeed, this is a very common place to start, but we’ll see how it plays out. Here are videos of her running initially.

The most obvious thing in the side view is the lack of hip extension, indeed her hips never really reach neutral. This is certainly not ideal. But again, is it due to tight hip flexors? behind it is difficult to discern much in the sagittal plane (forward/backward), but there are some inefficiencies with how her upper body moves.  Upon exam, her hip flexors were moderately tight, but the most glaring deficit was a lack of external rotation in both hips, as well as excessive internal rotation. She also had a substantial amount of myofascial tightness in her lateral hips, which we addressed through manual techniques.

So we started with stretches for posterior hip flexibility.

Next she did a stability exercise using a step to accentuate hip flexion, which also will improve hip external rotation.

And another stability drill to ensure control during hip extension.

So after these stretches and stability drills, here is what her form looked like.

Notice the improved hip extension, as well as the improved efficiency in her upper body more visible from behind.

Again, her form is deceptive initially because it appears to be just an issue of stretching her hip flexors. But she has been faithfully doing this for some time. The lack of external rotation of her hips is playing a huge role because it also limits her functional hip flexion, which causes a quicker push-off on the rear leg limiting the extension. She responded well to these drills and should make steady improvements with consistent performance of these. Great job Kaylie!

Rough Landing: Hip External Rotation, is it needed for runners?

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This is Jonathan, an aspiring Boston marathoner. We met for a session without any significant pain or known issues, so everything should be perfect right? Here’s a video of his run form initially.

My first observation is how his left hip behaves upon impact, as well as the increased left side bending of his upper body at foot strike on the left side compared to the right side. Upon closer assessment, we found that his left hip is limited in external rotation (turning out), as well as extension.

Now why is external rotation significant with running? The hip just flexes and extends right? At the risk of getting too geeky here, it’s worthwhile to give a brief synopsis of why rotation is needed. As Jonathan’s left leg swings forward, it is flexing with the ground as it’s frame of reference, and the right leg is extending. This creates a natural right rotation of the pelvis, again with the ground as the frame of reference. So, relative to the ground, his left hip is flexing, but relative to his pelvis, the hip is also externally rotating (abducting too, but that’s for another time!). So, to answer the question, a healthy amount of external rotation is needed to allow for a graceful loading of the hip and core, without it, he has to compensate by loading his core in an asymmetrical and inefficient way. This can be a cause of low back pain with running, but thankfully Jonathan isn’t having any issues and addressing it now, is much easier than scrambling as you get closer to race time.

So here’s what we did to get the hips moving better. A general hip flexor stretch with the upper body helping (a good one for runners and anyone stuck at a desk!)

Next, a hamstring biased hip external rotation stretch.

Thirdly, a glute biased hip external rotation stretch.

And lastly, a stability exercise to tie it all together.

So after these drills, this is what he looked like.

Not a dramatic change, but he certainly looks more graceful and symmetrical through the hips and core. With consistent performance of these drills his form should become more efficient. Keep it up and perhaps we can do a ‘Jonathan reloaded’ post as training progresses. Great job Jonathan!

As a bonus, here’s another way to get improved hip external rotation. This is my favorite way to do it, but as part of this post’s session, we used the equipment on hand as this is where he will likely be doing his stretches most consistently.

Back pain due to hip weakness

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This is Taylor, a collegiate runner. She has had back pain off and on for several months. Her Athletic Trainer has told her that she has ‘dumb butt’ syndrome. I’m not particularly a fan of the term, but it’s understandable what he was referring to. I asked her what his basis was for that statement and she mentioned lying prone on the table and raising her legs. This isn’t a bad test, but we need to know what this looks like with running and what we can do about it. Here’s video of her running initially from the side and behind.

From the side, notice the poor knee drive and landing with her knees relatively extended and moderate overstride. With landing like this, the ground reaction forces will be accentuated and not properly absorbed throughout the calves, quads, and more importantly the glutes.

From this angle you can see how her hips have to travel side to side with each stride, this indicates that it’s requiring extra effort for the glutes to tolerate each landing well. The fallout of this is how much her spine is having to rotate to accommodate for this. Any wonder where the back pain is coming from?

So here are some drills we did to get the hips working properly. Full disclosure, we also did some manual therapy for hip flexibility that isn’t shown, but complemented the movements done here.

First, hip flexor flexibility in all three planes of motion.

Next, glute activation/loading in all planes.

Lastly, a simple form drill on the treadmill to practice knee drive.

After all this, here is what she looks like from the side and behind.

Notice the improved knee drive from the side which allows for happier landing and loading through the hips. From behind you can see that she has less side to side motion in her hips and low back. In the videos she’s certainly working hard to focus on the drills we worked on. As with anything, it will become more natural as she consistently works on these things. Great job Taylor!

Knee pain due to hip/core weakness

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This is Caleb, an elite collegiate runner. He has had intermittent pain in his left medial/anterior knee, medial shin, and lateral hip. Watch the video of him running to get an idea of where this might be coming from.

As you can likely see, he has a lot of frontal plane movement of his upper body (side to side). Ideally the movement of the head and shoulders should be minimal with side to side motion. This is usually caused by either weakness in the glutes, slow push-off in the forefoot, or some combination of both. I’ve known Caleb for about 7 years and can say that he’s one of the most diligent, hardest workers I’ve met, so watching this pattern is not because he hasn’t done enough side planks or other common core activities to strengthen. The issue rather is that the movement patterns themselves haven’t properly been developed. So, here’s a single leg drill that shows more closely the limited stability in the frontal plane, notice the difference in the right leg versus the left.

As you can see, he’s a little more shaky and slow to load and push-off on the left side compared to the right. Again, when tested individually according to traditional muscle strength testing, his muscles are strong, but when tested in a functional setting, there’s a breakdown in how quickly the load/explode occurs.

So, we need to figure out how to develop that side to side control, which will help him become a more efficient runner and hopefully decrease chances of injury. Here is a video of him running holding an 8# ball overhead, this makes it nearly impossible to have excessive side to side motion with running.

Notice how his core/head stayed more steady, but how much of a struggle it is for his hips and feet. This is a drill I encouraged him to do, with or without weight. Here are a couple other exercises for developing this pattern.

Again, Caleb has a few thousand miles on his legs, with some pretty established patterns, so we don’t see a huge change as far as before and after session, but here is a video of after the session, as well as while holding hands overhead to take away the upper body motion.

You can notice how his legs become more unsteady with hands overhead. Again, he has been relying on his upper body to absorb and rebound a lot of frontal plane forces, so when the hands go overhead, his upper body isn’t able to do this anymore, thus his hips and feet have to figure it out more, this will be a work in progress, but could certainly lead to greater efficiency with running. Good job Caleb!