Physics...Physiology...Physical Therapy

Lateral knee pain due to IT band tightness

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This week’s spotlight is on Elizabeth. She is in training for her first half marathon and began experiencing left lateral knee pain following a 10 mile training run. She has been very active with team sports and plyometric workouts in the past, but running 10+ miles is uncharted water for her. Here is video of her running initially.

The thing that jumps out the most is the apprehension to load the left leg. The load-to-push-off transition should look very smooth, but her’s is certainly a little jerky (there’s probably a more technical term out there but we’ll roll with this one!). This type of pattern can come from the foot, calf, knee, hamstrings, or hip. Upon closer exam, she was very tight in the lateral hip and IT band.

These areas are especially critical during the loading phase of gait as the lateral hip should be where the majority of the shock of impact is absorbed. If this doesn’t happen gracefully than the IT band can easily tighten up and cause increased friction at the knee.

The other thing that jumps out is how much her arms and upper body rotate, a little more than ideal. The arms often tattle on how well the hips and core are dealing with the forces entering and leaving the body. See the last blog post for a little more on this and what to do about it!

But here’s what we did to get Elizabeth going again. First the good old foam roller to her IT band.

Next a two-stage stretch for the lateral hip.

After the foam roller and stretch, her hip flexibility already showed improvements, so here’s footage before we monkeyed with form drills.

As you can see, her left leg looks much smoother, but we’ve still got the extra rotation of the upper body and arms. So here’s what we did to address the form. First, power skips.

Lastly, she ran with her arms out to the sides. This increases the rotational lever arm and forces her lower core to be more stable while running.

As she did the last drill, she commented on how hard it was to keep her arms from swinging around. Again, what this does is teaches the lower core and hips to be able to more quickly and efficiently load and rebound to push off, rather than pass the buck to the upper body.

After all this, here’s the new and improved form.

Again, her landing and push off look much more efficient. Her upper body has less rotation to it, even though she looks a little over cautious in the last video. Ideally the arm swing is relaxed and relatively forward/backward. Her’s is certainly a step in the right direction. With consistent attention to her flexibility and improved form, this will keep stress off her knee and improve her efficiency. Great job Elizabeth!

 

Core is a movement, not a place

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‘Core’ is such a buzzword in the health and fitness world. But what muscles comprise it and what does it actually mean? We can all think of ‘core’ exercises (e.g. planks, crunches, etc), and we’re core-rect about that (sorry, couldn’t help it!), but we’re selling ourselves short if we are satisfied that these will get us the results we want. Let me also be clear, if the results you want are simply to look good, then planks and crunches will go a long way, but if you want a functionally strong core, then we’ve got to dig deeper.

Since this is a running blog, we’ll keep it in the context of running. Someone please stop me if this gets too geeky.

Think of your core as the place where movement initiates from and pivots. This can vary slightly from person to person. As you lift your knee to take your first step, a series of muscles need to fire to make it happen, this should start around the lower abdominal region, then the hip flexors, quads, tibialis anterior, etc. From there, every time your foot hits the ground, there is a force that travels up your leg (think Newton’s law: for every force there’s an equal and opposite force), as a result of your body weight striking the ground. As that force travels up your leg, your leg muscles should contribute to the shock absorption (think bucket brigade). When that force hits your hip and lower torso area, it should be able to be quickly and readily absorbed, which loads those muscles and allows them to push-off for the next stride. At this point, your upper body should be helping to leverage your lower half in order to make it easy for the next push-off.

So essentially, the forces of your body should pivot around your belly button when you are running. Quite often, this is not the case. Quite often, due to weakness in our lower core, that force has to travel further up our torso before enough other muscles are involved to effectively put the brakes on and send the force back toward the ground. When this is the case, what it can often look like is excessive arm swing, straining of the neck and shoulders, forward trunk lean, or a head that moves too much. Here are a few examples.

What these all have in common, is that their arms and upper bodies are tattling on their cores. Essentially, they have to use their arms and upper bodies differently to help absorb and leverage the forces that should be taken care of in the lower core. This amounts to decreased efficiency and performance and higher susceptibility to pain.

So, let’s pick on traditional core exercises again for a moment. What’s typically lacking is the vertical component for how the muscles need to work. This often means that key muscles (gluts, pelvic floor) don’t get strengthened in a way that actually translates to the demands of running. Can’t you just hear your six-pack muscles saying ‘thank you! can I get some help from below?!’ Here’s an example of a progression that engages your core in a way that translates to running.

There are several ways to modify this also. By using a 5-10# weighted object, that will increase the load, and make you work much harder. By taking bigger strides and going deeper into the lunge, that will increase the workout also. This can also be done as a run form drill, by holding in your arms in any of the 6 positions, based on what tendency you may be trying to overcome. What you should be feeling is the your hips and lower core region is working much harder to keep stability, since you are effectively taking your upper body out of the equation, or biasing it toward a direction of weakness.

Hopefully that all makes sense. Perhaps a more lengthy video with verbal explanations and demonstrations would be helpful. Please let me know if you would like to see this explained in more detail. Let me know how this goes for you!

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!