Physics...Physiology...Physical Therapy

Tight calves and affect on knees

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We tend to think of our calf muscles as being used for pushing off with our feet. But is that all they do? What, if anything, do they have to do with landing during the running cycle? As your foot hits the ground and your body advances over the planted foot, your calf will serve to put the breaks on your lower leg, essentially allowing for some knee flexion. Too much or too little can be problematic.

This brings us to Nicole. She has been a team sport athlete and will be competing in cross country for the first time in the fall. She is not new to running in the context of team sports, which is more sprinting and changing directions. She is however new to the distance running, and her stride has adapting to do. When we met, she had no complaints of pain, so hopefully our time together keeps any aches and pains away!

Two things jump out from her initial running. First, she has extra upper body rotation. This can be seen by her arms swinging across her midline. She isn’t too bad with this, but there is a slight asymmetry as well, with her left arm swinging further across than her right.

Secondly in watching her knees, they don’t bend quite enough. What should be seen is a comfortable loading, much like loading a spring so she can push-off efficiently. Instead, her knees remain slightly stiff which is an indicator that her calves are not allowing for this. Restricted ankle mobility can also be a contributor.

Here’s an assessment for how her upper body, hips, and ankles are moving. It’s subtle, but notice how her feet move as she rotates.

As she rotates to the left, her foot moves more than her right foot moves when rotating to the right. This indicates a restriction somewhere in that pattern of movement. This could certainly lead to other issues in the future!

So, what to do about it. First, we stretched her calves, not only straight forward, but also with a rotational emphasis. This is a great stretch for all runners!

Next, we practiced loading her knees and calves. Having her arms to the opposite side causes the calves to work harder since her gluts are disadvantaged in this position. This also helps bias her upper body to be more comfortable rotated to the left. She also performed single leg squats with the other leg.

Next, a simple run, but with her arms reaching down and forward. This also places more load on her calves during the landing phase, which will translate to greater ease during normal running.

She also ran with her arms to the left, again to bring better symmetry through her hips and upper body.

And what session would be complete without some form of hip stretching!

After all this, here’s the new and improved Nicole!

Notice her landing looks more graceful, because her calves are allowing the knees to come forward slightly more. Even a slight change in this area makes a huge difference to how well she is able to push-off and use her hips for stability. There is still more rotation than desired of the upper body, but this should improve as she gets stronger and uses her body more efficiently. Great job Nicole!

Foot position and hip flexibility

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Does your foot position matter? We can mostly all agree that it’s a bad idea to have a heavy heel strike with an overstride (more on that in another post!), but what about the other directions? Does it matter if feet are turned in or out? That brings us to Max’s story. He is a superstar high school runner looking to improve his running form. He doesn’t have an injury or limitations, but his feet tend to turn in which may be affecting his performance. So let’s break it down, here’s video of him running initially.

And here’s another with him running on his toes. The significance of using this as an assessment tool is to see how stable his feet are during the push-off phase, keeping him on his toes greatly minimizes the loading phase. This is where the minimalist movement really takes this concept and runs with it, but again, that’s a topic all it’s own.

And another with the instruction to take as long of strides as he can. This emphasizes the loading or landing phase of running.

If you contrast the two videos where he is running on his toes versus the longer strides (which leads to a heavier heel strike), he certainly looks sloppier through his hips and core during the longer strides. It’s subtle in the videos of him running normal and staying on his toes, but becomes more apparent in the third video. What is most obvious is how much extra movement occurs in his upper body. What this indicates is that his hips and feet are not able to adequately absorb the landing, causing his core and upper body to find goofy ways to leverage themselves so he can keep running. Will this affect his performance? Absolutely.

So, what to do about it. First, here’s a simple assessment for how well his hips are able to rotate. This is testing his hip’s flexibility with external rotation, which is critical for a smooth landing with running (and walking for that matter!).

As you can see, he is able to get about 45 degrees of rotation with this, at least 60 degrees is ideal. This combined with his running assessment tells us that he needs more flexibility in this direction, as well as the gross muscle stability to maintain good form in this direction.

Here’s what we did for Max. First a simple inner thigh/groin stretch. The key to this stretch is to keep the ground foot turned out to push the external rotation of the hip.

Next, another stretch for the posterior hip, also to gain better external rotation. If you’ve followed the blog, this one may look familiar!

Then we transitioned into stability exercises, again emphasizing core/hip movements into hip external rotation.

Here is what his run looks like after the stretches and stability exercises.

As you can see, his upper body looks more efficient and relaxed, which indicates that his hips are doing a better job of handling the landings.

Here’s a simple drill to do while running in order to build more stability/efficiency in the hips and core. By taking the arms out of their normal swing, it doesn’t allow him to use his upper body as much which forces his hips and lower core to be more stable.

After all this, here is what his run looks like.

Again, his upper body and hips look much more quiet and relaxed, which indicates that his hips and feet are better accommodating the landing phase. With consistent attention to his hip flexibility and building up strength and stability, he will see his form improve which should translate to better performance during races and workouts. Great job Max!

 

 

Knee pain in a jumper

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This is Jeremiah, he is a stud high jumper and runner who has had right anterior knee pain, which is his jumping leg. Our discussion today is in the context of jumping, but the biomechanical principals certainly carry over to running as well. We didn’t take any footage of him running, but this video of a single leg squat tells us plenty!

There’s a lot that can we can draw from watching him do a single leg squat. As you can imagine, every time he jumps off his right leg, he has to load that leg in a squatting movement. The biggest muscle groups that are responsible for propelling upward to jump are the gluts, quads, and calf. So the question that helps us is, how do these muscles know when they have been loaded enough to propel him skyward? There are a few factors that go into the answer. In order to engage the foot and calf, the big toe and medial forefoot have to be driven into the ground to their end-range. In the video, you can see his forefoot pronate heavily, which causes his knee to fall inward rather dramatically. In order to push off, he needs to have a rigid forefoot to propel with, which happens at the end-range of forefoot pronation. Only when his forefoot reaches the end-range of pronation, do the bigger muscles further up the chain (calves, quads, gluts) get the signal that it’s time to push off.

I realize that became a little geeky with the biomechanics, but stick with me. What it boils down to for his knee, which is where the pain has been, is that when it comes time to push off, his knee is at an awkward angle, which means that the quads are pulling on the tendon (front of knee cap) from a direction that is dysfunctional and weaker. This causes increased stress on the tendon and certainly affects his ability to perform.

So, what to do about it. What is tough to discern from the video, is that structurally he has forefoot varus, which means that when his ankle and heel are in a neutral position, his big toe is off the ground. This is a common thing, and most people with this type of foot appear to be flat-footed. One of the first things we did is put a little pad under the base of the big toe. This will hopefully be a temporary measure to cause the forefoot to load more quickly and keep the knee in a happier position. We also did this exercise to encourage the whole leg to stay in more proper alignment. The pull of the thera-band forces his gluts to fire more quickly, as well as strengthens the medial quad (VMO), and helps teach the foot and knee to stay in better alignment.

As you can see, his foot has to struggle to keep proper alignment. It certainly will take some work to build a better habit with this. Here is another simple exercise to strengthen a foot that demonstrates these types of patterns.

Again, with constant practice to build strength and consistency, this will help keep his knee in better alignment and get rid of the knee pain. Keep up the good work Jeremiah!

These principles also carry over to running. If you think this may be an issue for you, watch yourself do a single leg squat in a mirror, if your knee is dipping inward excessively, you might respond well to these exercises as well. Let me know how it goes.

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!