Physics...Physiology...Physical Therapy

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!

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!

Medial knee pain for a first time marathoner

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This is Ben. He is in training for his first marathon. He has no major concerns with musculoskeletal issues, but does have intermittent right medial knee pain, especially when increasing the mileage. Here is his run form initially:

The first thing that jumps out is the moderate toe out on the right side. The second thing from this angle is the asymmetry with arm swing and spinal rotation with left rotation being greater than right. My theory with this is that he is spending more time in the loading phase of gait on the right leg with a slow transition to push-off, thus his core is spending more time rotating to the left than the right. Here is another video of a test for ankle/calf/foot mechanics to see if that’s where the issue is.

It’s subtle, but notice how his right knee goes inward more than the left, as well as how his right hip has to rotate more than the left to accommodate the squat motion. This asymmetry lines up with what is seen with running. Also, if his right knee goes inward (increased valgus), this will cause repetitive stress on the MCL, pes tendons, and medial patellar capsule. This is the most likely culprit for his medial knee pain.

So here are a few exercises he is doing to work on calf/ankle/foot mechanics, as well as create better symmetry through the hips and core.

And since I can’t help but mess with run form a little, he also did a modified A drill on the treadmill.

After all this, here is a follow up video of his run after briefly performing these exercises.

Notice improved symmetry in the core and hips, as well as less toe out on the right foot. He will be doing these as a warm up for each run and hopefully will make another appearance to show off. Great job Ben and good luck with your training!

Calf pain in a sprinter

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This is Ashlee, a collegiate sprinter who has had significant calf pain to the point where surgery for compartment syndrome had entered the conversation. Here is a brief video of her running, obviously not at top speed.

It’s a little difficult to see in the video, but my first impression was how awkward the push-off phase of her form looked. The most obvious thing in the video is how much she has to shift her hips laterally away from the pushing off foot. Upon closer examination, her biggest deficits were lack of full ankle inversion and dorsiflexion, as well as hip extension and internal rotation. These ranges are needed most at the point of push-off, regardless of the speed or stride length. Typically sprinters will run more gracefully on their toes and at faster speeds, but Ashlee looked just the opposite. The push-off phase is even more critical when sprinting or toe-running. If a runner looks worse on their toes, it’s a good bet that there is foot weakness or mobility restrictions affecting their ability to push off properly.