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!

Forefoot pain due to big toe restriction

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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

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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!