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!

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!

Knee pain due to hip/core weakness

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This is Caleb, an elite collegiate runner. He has had intermittent pain in his left medial/anterior knee, medial shin, and lateral hip. Watch the video of him running to get an idea of where this might be coming from.

As you can likely see, he has a lot of frontal plane movement of his upper body (side to side). Ideally the movement of the head and shoulders should be minimal with side to side motion. This is usually caused by either weakness in the glutes, slow push-off in the forefoot, or some combination of both. I’ve known Caleb for about 7 years and can say that he’s one of the most diligent, hardest workers I’ve met, so watching this pattern is not because he hasn’t done enough side planks or other common core activities to strengthen. The issue rather is that the movement patterns themselves haven’t properly been developed. So, here’s a single leg drill that shows more closely the limited stability in the frontal plane, notice the difference in the right leg versus the left.

As you can see, he’s a little more shaky and slow to load and push-off on the left side compared to the right. Again, when tested individually according to traditional muscle strength testing, his muscles are strong, but when tested in a functional setting, there’s a breakdown in how quickly the load/explode occurs.

So, we need to figure out how to develop that side to side control, which will help him become a more efficient runner and hopefully decrease chances of injury. Here is a video of him running holding an 8# ball overhead, this makes it nearly impossible to have excessive side to side motion with running.

Notice how his core/head stayed more steady, but how much of a struggle it is for his hips and feet. This is a drill I encouraged him to do, with or without weight. Here are a couple other exercises for developing this pattern.

Again, Caleb has a few thousand miles on his legs, with some pretty established patterns, so we don’t see a huge change as far as before and after session, but here is a video of after the session, as well as while holding hands overhead to take away the upper body motion.

You can notice how his legs become more unsteady with hands overhead. Again, he has been relying on his upper body to absorb and rebound a lot of frontal plane forces, so when the hands go overhead, his upper body isn’t able to do this anymore, thus his hips and feet have to figure it out more, this will be a work in progress, but could certainly lead to greater efficiency with running. Good job Caleb!