Physics...Physiology...Physical Therapy

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!

Hamstrings bend my knee right?

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The hamstrings are a misunderstood group of muscles. When most people think about hamstring health, the first things that come to mind are usually stretching by touching your toes, standing or seated, or strengthening by seated hamstring curls on a weight machine. Do these stretches/exercises target the hamstrings? Absolutely. Do they teach the hamstrings how they are supposed to behave in functional movements? Hardly.

So this begs the question: what do your hamstrings do and how do we properly train them? The answer: it depends. It depends on what you do. This will look different for a runner compared to a farmer, or a soccer player compared to someone sitting in a desk all day. For the purposes of this post, we’ll keep it in the context of running. Quick anatomy lesson: the hamstrings are a group of three muscles that originate from the ischial tuberosity (sit bone) and extend past the knee, two out of the three on the inside of the knee, the other attaches to the head of the fibula on the outside of the knee.

There are three primary phases for each leg with running: 1) swing phase, 2) loading phase, and 3) push-off phase. The hamstrings have different functions during each phase and it’s important to understand what’s supposed to be happening at each. Also, most of the discussion will focus on the sagittal plane of movement (forward/backward), as this is the most obvious direction to observe. There are movements and forces in the transverse plane (rotational), and frontal plane (side to side) that we’ll touch on, but focusing on the sagittal plane will help keep details a little cleaner.

Swing phase: This is the ‘open chain’ portion of the cycle where the foot is off the ground swinging forward. During this phase the knee should bend as the hip flexes. The hamstring is not responsible for this knee bend, but rather the hip flexors driving the femur forward and momentum of the lower leg created by the push-off. The hamstrings during this phase are partially responsible for slowing down hip flexion as the swing phase ends, but are relatively quiet at the knee.

Loading phase: This is where the fun begins. As the foot touches the ground and body weight is loaded onto the planted foot, the hamstrings become more awake. At the knee, the hamstrings are mainly responsible for keeping the knee stable, not allowing terminal extension too quickly, nor allowing the knee to further flex. (The soleus is mainly responsible for controlling the knee during loading phase, but the hamstrings also assist with this.) At the hip the hamstrings eccentrically control anterior pelvic tilting, which translates to preventing trunk/pelvic flexion and ultimately keeping your upper body upright. The tricky part about this phase is that the hamstrings are responsible for both the knee and hip. As long as the knee and hip are behaving, than all is good, but if there is dysfunction in any of the adjacent joints or muscles, than this can cause a brief, unhealthy, tug-of-war which can quickly translate to a strain or pull.

Push-off phase: At the transition from loading to push-off, the hamstrings act like a catapult helping to propel the hips forward over the fixed lower leg. The hamstrings assist with extending the knee at this point to allow for full push-off. Then the leg is back into swing phase.

Again, when considering hamstring health, it’s most effective to train them in a way that translates most directly to what they need to do for the specific activity. The majority of the hamstrings’ contribution to running occurs with the foot planted on the ground. Because of this, the most effective hamstring exercises are done with the foot on the ground or planted on something, and the upper body mimicking the movements that occur during running. Here are a few examples.

First, a stretch for the hamstrings with rotational reaches to target different parts of the muscles.

Next, a strengthening progression, essentially a single leg deadlift, then hip rotations to strengthen the hip rotators.

Lastly, a variation of the single leg deadlift with theraband around the knee to challenge control in keeping the knee out of early terminal knee extension.

Give them a try or pass these on to someone who may appreciate better hamstring strength or flexibility. Let me know how you do with them!

Lateral hip pain due to lower ab weakness

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This week’s superstar is Amber. She has had lateral left hip pain off and on recently. No injuries, just progressive onset during the winter. Maybe we can blame it on the weather or lousy roads. Either way, this is what she looks like running at a normal speed.

And this is what she looks like running at a faster/tempo pace.

From behind in both videos, her left hip doesn’t appear to load as efficiently as the right. During walking or running, there should be a loading phase during which the glutes lengthen to accept the body weight, which then allows the glutes to have more power potential for push-off. Initially, her left hip seems to avoid the loading, which is where her pain is coming from.

From the side, we see limited knee drive as well as high arm swing. Both of these are often found with weakness in the lower abs, as her upper body will attempt to compensate by pulling the hips into flexion.

So we need to get her hip loading more efficiently and get her lower abs fired up. Firstly, a stretch for the glutes. We also did manual treatments for gaining hip flexibility, but this is what she will be working on at home.

We also did a lower ab dynamic strengthening exercise using an exercise ball. I think she really enjoyed this one!

After gaining flexibility in the hip and firing up her abs, this is what her running looked like.

Notice more symmetry and efficiency with loading of the hips from behind. Notice also the improved knee drive and more relaxed arm swing in the video from the side. Again, when muscles are loaded properly, they are able to work more efficiently. With Amber, consistent attention to hip flexibility and lower ab strength will help keep her running faster and faster. Great job Amber!

Abdominal strain due to thoracic restrictions

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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!

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!