Physics...Physiology...Physical Therapy

Abdominal strain due to thoracic restrictions

//  by //  Leave a Comment

This week’s spotlight is on Owen. He is a rockstar runner experiencing right upper abdominal muscular pain. No specific injury, but rather slow onset with running, unless he lied to me and does cage fighting at night! Let’s see what his run looks like.

Notice the asymmetry in his shoulders and arm swing. The right shoulder carries lower than the left and there is increased swing in the left arm.

The joint mechanics of the thoracic spine and rib cage are what we call ‘coupled’, which means that there are always combinations of rotation and side bending going on. For Owen, his thoracic spine did not left sidebend or right rotate as efficiently or as far as the opposite directions.

We also did another assessment for hip flexor tightness.

It’s subtle, but he is slightly more limited on the right side, as indicated by his upper body not bending backward as far with left foot forward, compared to the right. Tightness in the psoas is a very common issue and can limit hip extension, as well as trunk extension and rotation.

Before doing exercises, he spent time on the treatment table to loosen up his hip flexors and diaphragm. Upon palpation, the right side of his diaphragm was tight and reproduced his upper abdominal pain. This leads me to believe that his limited psoas flexibility, as well as asymmetric thoracic motion is causing poor flexibility of the right side of his diaphragm.

So here’s what we did about it. First a thoracic mobility exercise.

Next a core/hip flexor stability exercise using arms to drive motion through the thoracic spine and rib cage.

We also threw in a thoracic/hamstring stretch, again to get his thoracic spine moving as cleanly as possible.

After these exercises and manual treatment, here is the new and improved Owen.

Notice more symmetry with arm swing, indicating rotation of his core is more even, and the shoulder height discrepancy is decreased. Activities to keep progressing his balance and symmetry of movement will be essential for him to get rid of the pain and become a more efficient runner. Keep up the great work Owen!

Forefoot pain due to big toe restriction

//  by //  Leave a Comment

This week’s spotlight is on Kylie. She is a rockstar runner who has developed forefoot pain in her right foot. Here is her run before we assessed anything else.

Overall she has good running form, but what jumps out the most is a slight toe out on the right foot and increased circumduction of the right lower leg (swings in a circular motion out to the side, instead of straight forward). These are subtle, but signs of poor push-off on the right side. Here are other tests we did to tease out how her foot is working.

The above video is assessing her foot stability in the frontal plane (side to side motion). Notice after a few reps how her big toe and medial forefoot starts popping up off the ground. This is often a sign of poor joint mobility or weakness in the peroneus longus muscle, but more on that muscle at a later time!

Again, notice how far her right knee goes into a valgus position (knock-kneed) in this test. This is usually a sign of lateral hip weakness and/or limited forefoot stability.

We also checked for specific joint mobility on the table which demonstrated limited right big toe extension. Before progressing into exercises, we spent a few minutes loosening up the medial arch of her foot and big toe joints. Once this became more symmetrical, we progressed into exercises to improve the push-off and forefoot stability of the foot, as well as working the entire leg to make sure the hip is on the same page with the foot.

In this exercise, the goal is to promote clean push-off by driving the calf and tibia into external rotation, while encouraging the forefoot to stay planted on the ground, this works the forefoot and especially the big toe into the ranges it needs to be in fore push-off.

Next, she did a single leg drill to simulate the transition to pushing off through the hip and foot, notice a slight heel raise on the right side, which we encouraged again to load the forefoot.

Lastly, she did a simple drill to locally train the forefoot stability and mechanics for push-off using a half roller. To do this one most effectively, it’s important to have the foot angled from one corner to the opposite, which will encourage the intrinsic foot motion needed.

After all this, here’s what she looked like on the treadmill.

In the after video, her right foot and lower leg look more graceful, which indicates she’s getting a more effective load and push-off through the forefoot. There are certainly other factors that can be present which can assist with foot mechanics (i.e. hip strength, core strength, spinal mobility), but she responded well to our session today without having to monkey with form drills. Great job Kylie!

Medial knee pain due to ankle restriction

//  by //  Leave a Comment

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?

//  by //  Leave a Comment

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?

//  by //  Leave a Comment

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.