February snow storms are sure to continue, despite our spring running training and racing goals. Winter activities such as cross country skiing, snowshoeing, and backcountry skiing are excellent ways to build strength and cardiovascular fitness, while providing a much-needed break from running. It is very important, however, to condition our feet and lower legs for the impact of spring running. Ski boots provide more support and rigidity compared to running shoes. Combine increased foot and ankle support with a low impact descent on skis, and the stage is set for spring running injuries.
Running places unique eccentric demands on the musculature of our feet and lower legs. During an eccentric contraction, a muscle contracts in a lengthened position to resist an opposing force. Greater demand is placed on muscle and connective tissue (tendons) during eccentric contractions. Running freely down a rocky mountain trail requires eccentric muscle strength. Now is the time to prepare your body for running with a few simple, targeted drills to make you more durable when the snow and ice melt.
1. Heel Raises-Drops: Increase the tensile strength of the Achilles tendon and calf musculature to reduce tendinitis and muscle strain.
2. Quick Feet Drills: Rapid, low impact footwork to boost agility and balance.
3. Plyo-Hops: Build power and shock absorption capacity with powerful bounding hops and cat-like soft landings.
4. Split Squats: Slow eccentric loading in a squat position followed by a burst and weight shift for leg and core strength.
5. Runner Lunge Hops: Stabilize-Hop- Stabilize-Repeat sums up the runner lunge hop. Try holding your position for 5 seconds when you land the hop portion of the runner lunge.
As with all strengthening exercises, slow, intentional movement with an emphasis on form and balance should be primary. Sufficient gluteal, core, and extremity strength is necessary before attempting an eccentric strength-based exercise program. Contact the running injury prevention experts at Sapphire Physical Therapy with your specific training or running injury questions.
Unlike New Years resolutions which dissolve over time, following a few simple rules will greatly increase your chances of running injury-free in 2017. Understanding why runners get injured, setting realistic running goals, listening to your body, and doing the work it takes to be a runner will result in a successful year.
Why Runners Get Injured
Sixty million people ran for exercise in 20151 Running is a simple, effective means of achieving fitness which is accessible for very little financial investment. Running injuries, however, can be frustrating and expensive to treat. Nearly 80% of runners sustain at least one overuse running injury per year.2 Other than the occasional trip, slip, or fall, the repetitive dynamic forces generated and sustained during running often result in lower extremity injury. Among the twenty common running injuries, 70% to 80% of these injuries occurring from the knee to the foot.3 The most common running injuries include patellar tendinitis, meniscus tears, iliotibial band syndrome, patella femoral pain, shin splints, plantar fasciitis, Achilles tendonitis, hamstring strain, stress fractures, and ankle sprain. The underlying cause of running injuries, however, is functional weakness of the hips and core which causes excessive motion in one or more planes of motion.
Three different planes of motion act on the hips and pelvis while running: Forward/backward motion (sagittal), side-to-side motion (frontal), and rotational motion (transverse). Stabilization of motion in these three planes through targeted strengthening exercises will allow you to run more efficiently while greatly reducing your risk of running-related overuse injuries. A bi-weekly strengthening program must include activation exercises (finding and feeling the muscle working), strengthening exercises (fatiguing the muscle), and dynamic functional exercises (working the muscle in positions which simulate the demands of running). In addition to the gluts, core, abdominals, and lower leg musculature, the upper body and trunk must be strong and mobile.
Weekly mileage increases must be incremental. The age-old 10% mileage increase per week rule is a safe and effective guideline. A gradual increase in your weekly mileage will allow for adequate recovery between runs, allow for muscle strength gains to be realized, and reduce connective tissue (tendons, ligaments, fascia) overload. Remember, rest days are as important as high mileage days. Allow your body to rest, sleep, recover, and be ready to go following your rest day(s). Setting Realistic Running Goals
Motivation and mental fortitude is crucial to achieving training and racing goals. Physical training and a realistic understanding of your physical capacity will allow you to achieve success without injury. Seek the advice of training partners, experienced runners, and coaches to help set realistic racing goals. Once your 2017 running goals are established, create a training plan which includes terrain, elevation, distance, and temperature components similar to those expected in your upcoming races. Test your body and mind under these circumstances to confirm your fitness for your target race(s). Listen to Your Body
Because each of the 60 million runners who ran in 2015 are unique individuals, flexibility must be built into our training routines. Listen to your body when you are tired (How’s my stress level? When was my last total rest day?). Listen to your body when you feel good (What did you eat yesterday? How many hours did you sleep last night?). Listen to your aches and pains (Where do I hurt? Does slowing down my pace help?) Does increasing my cadence help? When did I last strength train? Do I need to see a professional so I don’t get sidelined?). Running through exertional pain is very different than running through injury pain. Listen to your body and get advice to learn the difference. Doing the Work
Running alone will not prevent running injuries. Less than ideal running biomechanics combined with repetitive motion associated with high mileage can stress muscle, connective tissue, and joints to the point of failure. Build up running durability through cross training, strength training, and adequate recovery. Have your running mechanics evaluated with a 2D video running analysis to document and visualize your biomechanics. Target your strength training to your individual needs rather than following a cookie-cutter program found online. Failure to do the work will greatly increase your risk of a running overuse injury.
Sapphire Physical Therapy is here to help you reach your 2017 running goals. Call us or email your questions and Happy New Year!
John Fiore, PT
Sapphire Physical Therapy
Two weeks ago I had the privilege of participating in Sapphire Physical Therapy’s new 2D Real Time Video Running Gait Analysis and I’m excited to share my experience. Sapphire has been a major partner in the Montana running community for many years and they continue to show their commitment to keeping us healthy and running strong as the only PT clinic in the Northwest to have an on-site 2D Running Gait Analysis System.” -Mike Foote, RE employee & The North Face ultra runner
What does a 2D Running Gait Analysis involve?
For all the amazing and detailed data you can collect from this analysis, the process is actually quite simple. The Sapphire staff just asked that I wear running clothes for the appointment. Upon arrival we discussed my running history and any current or chronic injuries I struggle with. I then hopped on the treadmill and ran while the surface was flat for a couple of minutes and also on an incline for a couple more minutes. Meanwhile they filmed me from two different angles with cameras which picked up on the LED lights they had taped to my body. These highlighted the actual angles of my joints as I ran in each phase of my running stride. After finishing, we then watched the video together in slow motion. Frame by frame we were able to see objectively what occurs in my running form.
What I learned about my form:
I went into the analysis with no current injuries, though, I have struggled with tendonitis in my right achilles and left posterior tibialis tendons. Through this clear data we found that my hip drops slightly on my left side, which led to an asymmetry that stressed my lower leg. We also found that my ankle dorsiflexes a little beyond the average angle. This too can cause unneeded stress on my lower legs and also cause me to be less efficient in my form. If this doesn’t lead directly to injury, it will indeed keep me from reaching the full potential of my competitive goals. We then discussed certain exercises I can do to address these issues.
Sapphire’s 2D Running Gait Analysis System is a fantastic tool in learning about what may be causing an injury or even exposing certain deficiencies which could lead to injury down the road. Though the amount of data produced in the analysis can feel overwhelming, the staff at Sapphire PT do a great job of breaking the information down into bite sized pieces for you to understand. They also then highlight a few actionable things you can do to address deficiencies and strengthen certain areas.
Who can benefit from this running analysis?
This is for all runners who have either been injured, are struggling from an injury or would like to avoid injury. Yep, that’s pretty much everyone! So, if you would like to utilize this great tool to improve your running and ward off injury, I highly recommend you schedule an appointment with Sapphire PT today. Check out their website explaining their Running Analysis and give them a call at 406-549-5283 to schedule an appointment.
Iliotibial band friction syndrome (ITBFS) is a common running overuse injury. Traditionally, ITBFS is diagnosed by the presence of iliotibial band tightness, pain to palpation along the lateral tibia (Gerdy’s tubercle), and pain to palpation along the distal IT band fibers. A common (although only partially accurate) explanation for IT band pain in runners is excessive friction of the IT band as it slides in an anterior-posterior direction as the knee moves from an extended to flexed position.i Further anatomical investigation coupled with the relatively poor results through conservative treatment of IT band pain warrant further explanation regarding the true underlying causes of lateral knee pain and ITBFS.
The iliotibial band is a large fibrous connective tissue band extending from the tensor fascia latae (TFL) and gluteal musculature. A closer look at the lateral leg musculature reveals the extensive vastus lateralis quadriceps muscle which travels beneath the IT band (from anterior to posterior). The vastus lateralis (lateral quadriceps) is often a muscle which is hypertrophied, tight, and tender to palpation in runners with lateral leg/knee pain rather than the often-accused IT band. Similarly, overuse of the TFL muscle increased tension which is transferred via the IT band to the lateral knee. The true compensations which occur during running (hip drop, cross-over gait, knee valgus, foot/ankle pronation) must be identified in order to effectively treat the cause of lateral leg/knee pain. A 2D video running gait analysis is an excellent way to identify and quantify biomechanical compensations.
ILIOTIBIAL BAND TIGHTNESS AND FRICTION: FACT OR FALACY
The IT band is not composed of non-contractile tissue. While the overlying fascia can be released through fascial release techniques (active release techniques, contract-relax, muscle
energy, integrated dry needling, ISTM, ASTM), the IT band itself is not capable of being tight or stretched. The surrounding structures, such as the vastus lateralis, TFL, hip and gluteal musculature, should be evaluated for weakness and/or dysfunction. The IT band is an extension of the TFL which encases the upper thigh. In addition to its attachment to the tibia (Gerdy’s tubercle), the IT band also has fibrous anchors to the femur, making significant movement of the IT band over the femur unlikely.ii A richly innervated layer of fatty tissue beneath the IT band becomes inflamed and painful when tension under load (running) increases through the IT band (Fairclough, it al). The cause of this tension, however, is the key to effectively treating ITBFS.
MUSCULAR IMBALANCE AND WEAKNESS
Muscular weakness in the gluteus medius and gluteus maximus muscles results in overuse or over-compensation of the TFL, and vastus lateralis. The thin TFL muscle is located on the anterior and slightly lateral aspects of the hip. Overuse of the TFL, which flexes the hip and internally rotates the femur, leads to increased IT band tension and irritation of the insertion on the lateral knee.iii The vastus lateralis, however, is often ignored when evaluating and treating lateral leg or knee pain. Similarly, our sedentary, seated lifestyles cause hip flexor muscle shortening (TFL, psoas, iliacus, rectus femoris) which leads to an anterior tilt of the pelvis and ineffective gluteal muscle activation and function. Without adequate proximal stabilization via the gluteus medius and gluteus maximus musculature, foot strike often results in an internal rotation of the femur, inward motion of the knee, and increased lateral leg and IT band tension.
ANKLE JOINT STIFFNESS
Stiffness in the ankle can limit dorsiflexion which is necessary for proper running biomechanics. Compensatory ankle eversion (toe-out position) and increased pronation (arch falling inward) increases the likelihood of knee valgus (knee collapsing inward). Such compensations at the ankle and knee joints increase lead to over-active hip adductor and TFL contraction and inhibited gluteus medius/maximus firing. Such compensations may be manifested as lateral leg or knee pain with the IT band being the alleged culprit.
Pain in the area of the lateral knee and proximal tib-fib joint which does not respond to conservative treatment or a thorough assessment of the true underlying cause warrants medical diagnostic testing. Second only to metatarsal stress fractures, stress fractures in the tibia and fibula are common due to the torsional stress through the long tibia and fibula while running. An X-ray may show a stress fracture, but the fracture may not show up on an X-ray prior to the formation of a bone callous later in the healing phase. Magnetic Resonance Imaging (MRI) may more accurately show a stress fracture but the cost is much higher.
Evaluation and treatment techniques, therefore, must effectively address each of the possible contributing factors, to bring about a comprehensive, effective, long-term solution. A physical therapist skilled in exercise and manual therapy techniques specific to runners can be a source of information and treatment knowledge to get you back to your favorite running routes and and trails.
A September 27, 2016 Outside.com article by David Roche (Nike Trail Elite team member) reminded me of the vast amount of misleading information found online regarding strength training for runners. While the article did list both pros as well as cons of strength training, the take home message of the article was “if you want to become a better runner, then just run, and run a lot.” Not only will this advice increase one’s injury risk, but it only truly applies to approximately 1% of the running population.
The other 99% of us balance family, full-time jobs, injury history, and less than perfect running biomechanics. For us, simply running, and running a lot increases our injury risk. An individualized, targeted running-specific strength training program is an excellent way to improve performance while reducing injury risk. Fortunately, the research supports the importance of strength training for endurance runners and now is the time of year to focus on strengthening in preparation for a successful, enjoyable, injury-free 2017 running season.
A 2010 research article in the Journal of Orthopedic Sports Physical Therapy showed a correlation between impaired muscular control of the hip, pelvis, and trunk and increased knee pain in runners.iA strength training program aimed at providing functional stabilization of the hip and pelvis in multiple planes is, therefore, a vital part of a knee rehabilitation program. A 2009 Journal of Orthopedic Sports Physical Therapy study analyzed the hip stabilization mechanics of twenty-one female runners with patella femoral knee pain compared to the twenty pain-free female runners.iiThe study confirmed increased hip/gluteal muscle weakness with associated femoral internal rotation (knee collapses inward) in the group of women experiencing knee pain. Finally, a 2015 research article in the International Journal of Sports Medicine looked at factors which contribute to the high incidence (19.4% to 92.4% of runners will experience a running injury) of running injuries.iiiThe study concluded that in addition to training errors, changes in the joint mechanics due to poor muscular strength increase injury risk in runners. Running form can be modified in subtle yet crucial ways to reduce joint impact force through resisted double and single leg gluteal, hip, core, and lower leg/foot strengthening.
Now that we agree that strengthening is important for runners, what is the best way to strength train? Should I do body weight resistance exercises only, or should I lift weights? If I lift weights will my muscles bulk up and slow me down when I run? While body weight resistance exercises are a great way to isolate single leg stabilization, weight resistance exercises (dumbbells, kettlebells, weighted bars) are necessary to build power and durability for endurance runners. Exercising on machines while seated will not build strength specific to running as balance and weight bearing are absent. If you are presently injured or have an injury history, consult a physical therapist training specifically to work with runners. The number one predictor of a future running injury is a prior running injury history. It is important, therefore, to have a physical therapist analyze your running biomechanics. At Sapphire Physical Therapy, our on-site 2D video running gait analysis system allows us to detect compensations which impact performance and perpetuate your running injury risk.
Fall and winter are the seasons to address compensations and weaknesses through an individualized strength training program. Sapphire Physical Therapy is here for the 99% of runners for whom this article applies.
The following are links to three Sapphire Physical Therapy videos. Each video emphasizes proper exercise technique, the target musculature of each exercise, and proper demonstration. Copy and paste each link to learn how to begin incorporating running-specific strengthening exercises into your training program: iv
1 dos Santos AF et al. The E ects of Forefoot … Int J Sports Med 2015; 36: 1–5 i Powers C. J Orthop Sports Phys Ther 2010;40(2):42-51. doi:10.2519/jospt.2010.3337 ii Souza R, Powers C. J Orthop Sports Phys Ther 2009;39(1):12-19. doi:10.2519/ jospt.2009.2885 iii dos Santos AF et al. The E ects of Forefoot … Int J Sports Med 2015; 36: 1–5
The hip complex is often a source of running injury and inefficiency. The cause of a running injury is often found in an area distant from the actual pain of the injury, and many running injuries are misdiagnosed due to the failure of not looking at the whole body and how it moves or doesn’t move. Failing to evaluate the hips of a runner often results in unsuccessful running injury treatment. Research has shown a correlation between gluteus medius weakness and iliotibial band pain (Fredericson et al.i). Taking a closer look at the running stride (through 2D high speed video running analysis) has objectively shown us how hip weakness can lead to overuse injuries in the knee, lower leg, ankle, foot, and low back as well.
The complexity of the relationship between the hip and pelvis while running deserves explanation. A delicate balance exists between the muscle length and muscle strength of the hip flexor and hip extensor muscle groups. When this balance is compromised (through pelvic level asymmetries, weakness, muscle tightness, joint stiffness) compensations subconsciously step in to enable us to run. These compensations, however, predispose runners to overuse injuries. Because each running stride results in a force 2.5 to 5 times greater than our body weight, subtle postural and strength asymmetries must be identified and addressed to effectively prevent or treat running injuries. An efficient, pain-free running stride begins with flexing the hip, but is complimented by hip extension of the opposite leg. While hip flexion initiates the running stride, hip extension provides the power needed to propel us forward efficiently. A delicate but crucial balance of postural symmetry (right and left sides of the pelvis), joint mobility (prolonged sitting shortens hip flexor musculature which may limit necessary hip extension), and strength (gluteal, hip, quadriceps, hamstrings, lower abdominals) must all be sufficiently present to allow the hips of a person to run mile after mile without pain or compensations.
It is important to understand the role our modern lifestyle plays in running injuries. Modern day humans sit way too much. Our ancestors did not experience the high incidence of running injuries we do because they were on their feet and constantly moving to support their subsistence lifestyle. Our hip flexors become tight and shortened with prolonged sitting. Our pelvis tips anteriorly with prolonged sitting, and the hip joints become compressed. The forward tilt of the pelvis due to tight hip flexors increases compression in the lumbar spine and inhibits the lower abdominals in their attempt to stabilize our core. Our gluts are overstretched and become dormant while our hamstring muscles shorten, making it difficulty for our gluts to extend our hips. Basically, our modern-day lifestyle predisposes our hips to dysfunction and necessitates proactive action on our part to make sure we are as mobile and strong as possible.
Addressing hip dysfunction (tightness, overuse, weakness) is not as simple as stretching your hip flexors. A thorough examination of a runner’s movement patterns, strength, and a video running analysis will collectively reveal the role the hips play in a particular running injury. Manual therapy is an important diagnostic and treatment technique to restore necessary hip joint motion and to release excessive muscle tension secondary to compensatory muscle use. Targeted strengthening exercises, muscle energy techniques, active stretching instruction, myofascial release techniques, and dry needling are among the skilled treatment techniques performed by physical therapists which can lead to tremendous results.
So the next time you are out running the trails or roads, take a minute to appreciate the reciprocal, efficient work being done by your hip flexor and hip extensor muscle groups with each stride. John Fiore, PT
Sapphire Physical Therapy www.sapphirept.com
i Fredericson M, Cookingham CL, et al. Hip Abductor Weakness in Distance Runners with Iliotibial Band Syndrome. Clin J Sport Med. 2000; 10(3): 169-175.