Physics...Physiology...Physical Therapy

Forefoot pain and hip weakness

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This is Jasmine. She is a superstar runner who is beginning her track season. Some of the issues she has dealt with include forefoot pain and calf stiffness. Her low back has also been sore at times. She is not limited with running, but these are frequent annoyances. Another quirk is that toward the end of a race or tough workout, her head tends to move a lot, sort of like a bobble-head. We don’t have any footage of that sadly, but you can catch a glimpse of it when close up! Here is video of her at the beginning of a run.

From behind, the most obvious parts are the increased loading time in the hips both sides and slowness to push-off through the feet. From the sideview, she has a forward trunk lean. What these indicate is weakness in her hips and core, especially in the context of loading in the sagittal plane (forward/backward). Essentially, every time her foot hits the ground, her hip and lower core region should be able to quickly absorb the force of the ground traveling up and transfer that to an efficient push-off. Instead, it takes extra effort to absorb that load, so she’s forced to lean forward and leverage her head and neck to pick up the slack. Ideally, her head and upper body should be fairly quiet and relaxed because the work is mostly picked up by the lower half.

So, what to do about it. We have already been working on the flexibility of her hips and calves, mostly working on posterior and anterior hip flexibility, which videos of others doing these can be found in previous posts of similar runners, as well as calf stretches with twists thrown in. Again, these can be shown in recent posts. So these videos focus on the running form aspect.

First, another assessment video. The instruction given was simply to stay on her toes. This can be a great way to discern how strong the forefeet are. Often, if the form worsens when running on the toes, that’s a dead giveaway that lack of foot strength is part of the equation. Indeed that’s what we see with Jasmine.

Here is a simple drill to emphasize quickness with the loading phase and power during push-off phase. I’ve heard these most commonly referred to as ‘power skips.’

Next, to develop proper core control in the sagittal plane, she ran with the most convenient object with a little weight to it, a purse!

What this accomplishes is that it forces her to stay more upright and stable through her upper body. This can be done with any object that weighs a few pounds, a backpack, a rock, or a small weight. From the side, her upper body certainly stays more upright, which is a great sign! From behind, her head and shoulders stay more stable, also a great sign!

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

From the side, she certainly looks more upright. From behind, her feet and hips look quicker and more efficient. So these are good indicators that the drills will be helpful for developing better patterns for stability and efficiency and should translate to better performance. Great work Jasmine!

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!

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 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!