How Sitting Can Increase Injury Risk

by John Fiore, PT

Runners are well aware of the importance of strength training to reduce injury risk. Even the most specific strengthening program will fail to produce results, however, if compensatory movement patterns are not addressed. Our modern lifestyle is filled with sitting. We sit at work, sit while driving, sit for relaxation, yet expect our hips, pelvis, and spine to function normally. Hip flexor tightness is synonymous with prolonged sitting. The psoas is in important hip flexor muscle which warrants further discussion to understand the challenge of running injury treatment and prevention.

The psoas is an important core muscle which stabilizes and moves both the lumbar spine and the lower extremity.  Collectively, the psoas and iliacus muscles are referred to as the iliopsoas muscle group. The psoas works in conjunction with the iliacus muscle.  While both the psoas and iliacus insert on the lesser trochanter of the femur (groin area), the iliacus originates in the iliac fossa and iliac crest of the pelvis and sacrum, whereas the psoas originates along the transverse processes of the lumbar spine. The primary function of the psoas muscle is to flex the hip. Secondary actions which are very important for proper lumbar spine and lower extremity function and symmetry include femoral lateral rotation, lumbar extension, and lumbar side bending. In addition, the iliacus tilts the pelvis anteriorly. Both the psoas and iliacus muscles activate unilaterally or bilaterally. Asymmetry between the right and left psoas muscles due to tightness or weakness, therefore, is an important source of one-sided low back and leg pain.  While psoas asymmetry is often overlooked, proper, targeted clinical testing must be included when thoroughly evaluating low back and extremity pain and overuse injuries.

The psoas muscle lifts the hip and leg forward when we walk, run, and climb. Overutilization of the iliopsoas can lead to postural and mechanical issues.  Without the necessary strength in the abdominals, hips, gluteal and small stabilizing lumbar (multifidi) musculature, the psoas becomes shortened, over-active, and irritated.  Gait and postural deviations may present as a laterally-rotated hip, an anteriorly tilted pelvis (unilaterally or bilaterally), or a sway back posture.  An iliopsoas-dominant athlete may develop a myriad of overuse injuries including:  psoas or groin pain, sacroiliac and low back pain, iliotibial band pain, and even knee and foot overuse injuries.

Once a psoas imbalance or overutilization issue is diagnosed, the resulting mechanical asymmetry must be addressed through manual physical therapy techniques. Targeted active release stretching, dry needling, deep tissue release, and muscle energy techniques are effective ways to restore symmetry and proper function to the right and left psoas musculature. Manual therapy alone, however will not “fix” the problem. Strengthening the antagonist musculature will allow the body to maximize efficiency of movement.

Strengthening the weak links in the modern day athlete can be difficult due to ingrained movement patterns.  Strengthening the lower abdominal and gluteal musculature, for example, reduces our reliance on the psoas to “pick up the slack” in lumbar and pelvic stabilization. Functional core strengthening involves the gluteal and abdominal musculature stabilizing in conjunction with sport-specific upper and lower extremity motions.  Sit-ups and crunches alone, however, may exacerbate the problem of tight or dominant psoas  musculature.  It is important, therefore, to include planks (prone and side positions) and single leg weight bearing core exercises to reduce habitual psoas use. Finding your lower abdominals (transversus abdominis) muscles when lifting is key to prevent the anterior pelvic tilt associated with iliacus activation as well as the lumbar sway back associate with psoas activation.  

Our modern day lifestyle of prolonged sitting and very little physical activity other than our “workouts” predisposes us to psoas muscle shortening and dominance.  Sitting inherently shortens the psoas while the antagonist muscle (gluteus maximus) is unable to function the lengthened position of sitting.  The most common area of weakness in present day athletes (based upon my empirical evidence of 24 years in practice) are the gluteus medius and gluteus maximus.  No wonder we have difficulty contracting our gluts when much of our day is spent sitting!  In addition to a physical therapy strength and postural evaluation, a video gait or running analysis will reveal muscle imbalances to address to effectively prevent and treat injuries related to a hip flexor or psoas domain state.  

Finally, for an aging athlete or individual, hip joint compression due to excessive sitting and associated psoas tightness can accelerate osteoarthritis.  Balancing proper muscle flexibility with core stabilization and strength will decrease the impacts of prolonged sitting to permit a healthy, active lifestyle for years to come.  

(John Fiore is the owner of Sapphire Physical Therapy in Missoula. You can reach him at john@sapphirept.com or 406-549-5283)

ARTICLE REFERENCES

  1. McGill,S.(2007) Low Back Disorders: evidence-based prevention and rehabilitation. 2nd ed. Human Kinetics. Champaign, IL. P 60-61, 214-217.
  2. Jones,S. Rivett,D. (2004) Clinical Reasoning for Manual Therapists. Elseier Butterworth Hinemann. New York, NY. P 261-274,
    3. Greives. Grieve’s Modern Manual Therapy. Harcourt Publishers Ltd. 19943
  3. http://www.serola.net/research-entry/iliopsoas/
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Uphill Running Technique and Training for Efficiency and Stress

by John Fiore, PT

With The Rut only four weeks away, now is the time to add a some climbing specific runs to
your training plan. Understanding which uphill running techniques work best for your body type, fitness, and experience will pay off greatly on race day.

Aerobic Fitness and Hill Interval Training:

Not everyone is a natural uphill runner, but natural ability is a small part of the uphill running puzzle. Aerobic fitness and high strength-to- weight ratio result in faster uphill times. Uphill interval training is necessary to build both aerobic and anaerobic fitness. Following a variety of uphill interval durations (from 30 seconds to 5, 10, 15 minutes) based on your running or racing goals will teach you how to effectively pace your efforts based on the terrain you are climbing. Uphill interval repeats will train your body to recover more efficiently at the top of a climb in preparation for the descent and the next hill. Uphill interval workouts are easy to find online, but Forrest at Runners Edge is a great local resource as well. He provides excellent uphill interval workouts during the current Rut Training Class. Basically, uphill intervals are not fun, they hurt, but you will hurt a lot more on race day if you have not done weekly uphill intervals, period.

Uphill Running Technique:

Body composition, aerobic fitness, and terrain dictate the most efficient uphill running technique. Below are examples of four uphill running techniques with some advantages and disadvantages of each.

Running every climb is obviously what every runner aspires to be able to do. When the grade kicks up for prolonged periods, however, energy conservation becomes important. A runner with a high strength-to- weight ratio (light but strong) and a high level of aerobic fitness may be able to run and leave the pack in the dust. Running posture should include an elongated trunk for breathing, slight forward lean to counter-balance gravity, short, quick, tall uphill strides, and rhythmical upper body arm swing. The energy cost of such superhuman efforts repeatedly during a run or a race can be huge, and slower but more efficient climbers may catch the fatiguing uphill runner. Again, know your limits by practicing your uphill running threshold during interval
training.

Power hiking with hands on thighs is the go-to technique for long, sustained climbs during long runs or races. Hiking uphill results in a lower heart rate which means you can sustain the effort for a longer duration. Gradient also dictates when a runner must resort to power hiking. Again, the gradient which requires hiking varies from runner to runner based on aerobic fitness and strength-to- weight ration. If you are being passed by power hikers and you are still slogging uphill in a run, then consider hiking. Using your hands on your thighs as you push off provides extra power, supports your upper body and spine, and allows for good breathing. Practice short, quick and longer, slower power hiking steps to see which technique suits your fitness and body type (leg length, strength) best. When you crest the top of the climb, transition back to running, breathe, and recover.

Power hiking with poles is similar to power hiking with hands on thighs, except the poles allow for longer stride length. Poles also aid in providing balance, and spread the muscle demand over four extremities rather than just two. Using trekking poles requires practice. Try an uphill interval workout with poles and practice pole placement. Poles provide great assistance while descending as well, and running-specific poles are light and can be easily stowed in your pack when not in use.

Uphill Terrain Running Agility:

It is important not to stare at your feet when running uphill. Look slightly ahead to plan your route and practice bounding uphill to increase your uphill running agility. Short, rocky, steep climbs are ideal for uphill bounding practice. Recover by jogging slowly back down the same hill. Feeling at home on varied uphill terrain (loose dirt, rocky trails, scree fields, and ridge lines) will insure confidence and efficiency on race day.

Upper and Lower Body Strength:

I may sound like a broken record, but strength is vital for efficient uphill running. Upper body strength will insure a rhythmical ascent and provide the counter balance for climbing legs. Using poles or hands-on- thighs both require upper body strength as well. A strong core will reduce the likelihood of low back stiffness or pain during prolonged climbs. Finally, moving your body weight uphill against gravity as quickly as possible requires strong quadriceps, hips, and gluteal musculature. For any specific questions related to uphill running technique-training, or injury treatment-
prevention, contact me at Sapphire Physical Therapy.

John Fiore, PT

john@sapphirept.com
www.sapphirept.com

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Downhill Running Form and Training Techniques

Downhill Running Form and Training Techniques
John Fiore, PT

The challenges of running uphill are addressed through uphill interval training and techniques specific to climbing. Downhill running, however, is often a forgotten aspect of training. While it is true that many races are won on the unrelenting climbs, races are more often lost on the long, technical descents due to blown quads and poor technique. I do not claim to be a stellar downhill runner, but I will pass on useful training techniques founded in running biomechanics which may help you make the Swift Current cutoff time or even soar to victory at The Rut this September.

Regardless of body type or speed, the following seven training tips will improve your downhill running form and efficiency and reduce post-running soreness and injury risk.

Commit to running downhill: When the climb is over and the gradient tips downward, shift gears in your mind and body and commit to descending. Your leg musculature must now function in the lengthened position referred to as an eccentric contraction. In a lengthened position, your muscles are prone to soreness which is minimized through specified training.

Lean forward and use gravity: A common mistake many runners make is to lean back on the while descending. This “back seat” descending techniques results in higher impact loading through the heel, a shift of the center of gravity behind the body, and a higher incidence of blown quads or sliding feet. Lean forward slightly through the pelvis and trunk, using gravity to your advantage. Downhill running is often viewed as controlled free-falling and can actually be as fun as it sounds.

Descending at the Chuckanut 50k

Move your feet quickly: Cadence plays a crucial role in increasing running efficiency by reducing joint impact loading and conserving energy. Increasing your cadence (160-180 foot strikes per minute) will decrease joint impact forces, reduce muscle fatigue, and reduce the incidence of tripping on a stray rock. Try seeking out rocks to land on rather than navigating around rocks as if you are crossing a stream.

Look down the mountain and anticipate your next move: When running uphill, it is best to look a step or two ahead rather than face the entire climb head-on. In contrast, when descending, keep your eyes five to ten feet ahead of your feet and anticipate your next two steps in your mind and your legs will follow. Practice this technique on a rocky familiar descent and train your proprioception (non-visual sense of foot-leg position in space).

Relax your arms and utilize your entire body for balance: Balance becomes more of an issue running downhill at speed. Utilize your arms for balance and allow them to flail wildly while maintaining stable, strong trunk and hip musculature. Core strength and joint stabilization will pay off on the descents and it is important to utilize a regular program to achieve functional running strength.

Simulate race terrain in training: If your upcoming race includes downhill running or technical, rocky terrain, it is imperative to practice on similar terrain. Missoulians are fortunate to have a choice of rocky, steep terrain less than one hour away in any direction from town. Rocky trails abound in the Bitterroot, Rattlesnake, and Mission Mountains. Practice downhill intervals, climbing back up, and practicing a different line and varying your cadence and foot placement strategies.

Emphasize eccentric single leg training: Runners tend to focus on step ups, squats, and non-weight bearing gluteal exercises, but the secret to confident downhill running lies in eccentric single leg strengthening. Utilize single leg plyo-hops, box jumps, and even single leg box jumps onto an uneven surface such as a pad or Bosu Ball to train your body to fly down the scree and talus slopes of your favorite mountain race. For more specific questions related to downhill running training, injury treatment or prevention, call or email me at Sapphire Physical Therapy.

 

John Fiore, PT

john@sapphirept.com

www.sapphirept.com

Hip Extension for Efficient Running

Hip Extension for Efficient Running

(Unlocking the mystery which drives running)
By: John Fiore, PT

Runners of all abilities and ages strive to run efficiently and injury-free. While the importance of foot strike pattern and cadence will be addressed in future articles, this month’s article will focus on the role of hip extension to maximize running efficiency and reduce injury risk. Runners are often given general cues to improve running form which often result in further compensatory running patterns. “Running with an upright trunk” and “drive your hips and pelvis forward” cues in reality inhibit true hip extension by increasing lumbar spine compression through an anterior pelvic tilt. The first step to running efficiently is to understand what hip extension is.

Hip extension begins as the body passes behind the center of gravity of the body (pelvis, torso) during the running stride. Hip extension (coupled with knee and ankle extension) produces the power phase which drives running forward propulsion. A strong gluteus maximus is a must for hip extension in runners. The gluteus maximus is the primary hip extender while the hamstring assists. In the presence of an underactive or weak gluteus maximus, the hamstring assumes the role of hip extension which often leads to hamstring muscle overuse injuries.

Photo courtesy of physiospot.com

It is difficult to evaluate true hip extension without a video running analysis with high- speed cameras to capture and objectively quantify hip joint extension angles. A real- time video running analysis will document hip extension while running. Think of a running stride as being comprised of two equal halves (hip flexion and hip extension). Similar to a pendulum, the hip excursion during hip extension (backward portion of the running stride) should approximate the hip excursion during hip flexion (forward portion of the running stride). Visualize your trunk and torso as the axis of a pendulum with hip extension equaling hip flexion.

Another function of hip extension is one of power transfer. Energy gained through gluteus maximus contraction and hip extension, is transferred into more efficient hip flexion during the forward swing phase of the running stride. A stretch reflex of the hip flexor muscle during hip extension results in a more efficient forward stride. Lifestyle consequences interfere with our natural, efficient running stride. Prolonged sitting increases the risk of hip flexor tightness (psoas, rectus femoris), an anterior tilt of the pelvis, and weak gluteal muscles (gluteus maximus, gluteus medius).

Restoring necessary hip extension while running is not achieved by running upright or driving the pelvis forward as many runners are instructed to do. Retraining the body to extend the hip while stabilizing the pelvis is possible only through core stabilization, functional (weight bearing) strengthening, and running video analysis. Without adequate pelvic stabilization, anterior tilting of the pelvis results in increased lumbar compression and increased hamstring muscle compensation.

Photo courtesy of pitchvision.com

The experts at Sapphire Physical Therapy can evaluate your running gait with our real-time 2D video running analysis. Based on the analysis data, an individualized functional strength, pelvis stabilization program will allow you to work towards pain-free running and detect underlying form or strength issues. Call Sapphire Physical Therapy or see learn more at www.sapphirept.com and let us help you successfully achieve your running goals.

John Fiore, PT

john@sapphirept.com

Proximal Hamstring Pain in Runners: Effective Injury Treatment & Prevention Guidelines

Many Missoula runners have already toed the start line of a race or two by now. Training for summer races is in full swing, and now is the time to add intervals, speed work, and mileage. As running speed and intensity increase, however, hamstring overuse injury risk increases. The hamstring is an important and complex, two-joint (crosses both the hip and the knee joints) muscle group used in running. While hamstring pulls and strains are common in runners and often healed with rest, proximal hamstring overuse injuries can be very debilitating.  Repetitive micro-trauma in the hamstring attachment at the ischial tuberosity of the pelvis may result in tendinopathy (acute tendinitis or chronic tendinosis) and pain. While proper diagnostic testing is key (clinical testing by an experienced physical therapist or by a sports orthopedic physician), insufficient or improper treatment of proximal hamstring tendinosis can be a season-ending injury.

Understanding the hamstring musculature is the first step toward injury prevention. The two-joint hamstring plays a role in two distinct movements. The hamstring’s primary function is to flex or bend the knee. The hamstring’s secondary function is to aid in extending the hip.  Because the hamstring crosses both the hip joint and the knee joint, it is a key muscle in the running stride.

The hamstring is comprised of three muscles.  All three hamstring muscles originate on the ischial tuberosity of the pelvis. The semimembranosus and semitendinosus muscles attach on the medial side of the lower leg (tibia) below the knee.  The biceps femoris attaches on the lateral side of the lower leg (tibia) below the knee. The hamstring muscle group works in opposition to the quadriceps muscles.  When you are flying down a hill at full speed, quads pounding and quads burning, the hamstrings act as the “brakes” to prevent knee hyperextension and to initiate the push-off phase of running.

Once diagnosed with a series of clinical tests by your PT which place tension on the hamstring origin or attachment, establishing proper treatment is crucial. Reducing inflammation by reducing running mileage and stride length must occur first. Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are stronger and more prepared to check the power of the quadriceps while running. Core strength addressing lower abdominal, hip, gluteal, and lumbar strength in a functional manner will complement hamstring-specific strengthening to reduce overuse associated tissue micro-trauma.

Decreasing pain is only one component of a proximal hamstring injury prevention and treatment plan.  Strengthening the hamstring in a manner consistent with running is key in preventing injury recurrence. In order to quantify hamstring function, a 2D video running analysis is important to determine how you as an individual run. Are you using your gluteus maximus to extend your hip, or is the hamstring acting primarily? Are you over-striding and placing increased tension through your hamstring? A 2D video running analysis is a helpful way to detect additional underlying running compensations which may influence running biomechanics and resulting hamstring stress.

A physical therapist will customize plan to resolve your hamstring pain. Treatments may include:  pain-relieving modalities, integrated dry needling, active release techniques, muscle energy techniques to balance pelvis symmetry, myofascial release, and contract-relax techniques to address pain and tissue restriction in the hamstring secondary to overuse.  A cortisone injection may be indicated by your physician if proximal hamstring pain is inflammatory (tendinitis) in nature.  Finally, do not forget self-care such as adequate recovery, sleep, release, and eccentric hamstring exercises during the summer running season.  The exercises listed below are examples, but I recommend seeing a physical therapist to rule out underlying injuries or referred pain to enable you to resolve symptoms and reduce the risk of re-injury.

Call or email John with any questions or comments.

John Fiore
Sapphire Physical Therapy
406-549-5283
john@sapphirept.com


Proximal Hamstring and Core Exercises:

1.  Quadruped plank: May be modified by resting on your forearms. Do not allow your lumbar spine to extend.

2.  Side lying glut isolation: Press into the wall with your heel and maintain a neutral pelvis position.

3. Quadruped hip extension: Contract the glut of your involved leg prior to extending your hip to decrease hamstring compensation.

4. Glut bridging: Contract your gluts (glut max) together and hold the contraction as you raise into a bridge position and hold for 5 seconds.  Slowly return to starting position and repeat for one minute. Further challenge yourself by repeating glut bridging exercise with the addition of single leg marching without allowing your pelvis to drop.

5. Eccentric hamstring-strengthening exercise using the treadmill: The treadmill is turned on to a slow speed, with the individual facing backward on the treadmill while holding on to the hand rails. The support side (the left leg shown) is placed off of the treadmill belt. The involved leg (the right leg shown) is extended at the hip while keeping the knee mostly extended, and the individual is instructed to resist the forward motion of the belt with the leg as the belt moves. The involved leg then is moved back to the starting point by flexing the knee and extending the hip.  Continue for one minute.

References:
1. Cushman, D.; Rho, M., Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2015, 45 (7), 557-562.
2. Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challenges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.

*Image from yoganatomy.com

Five Common Training Spring Training Errors to Avoid

Spring has arrived in Missoula and the roads and surrounding trails are filled with runners. Most runners have created a tenta
tive 2017 race schedule and motivation levels are high. Choosing the correct training plan, however, will likely determine your racing success over the next nine months. Whether you are participating in Run Wild Missoula’s Missoula Marathon Training Program, the Runner’s Edge Trail Running Class, utilize a running coach, or follow an online training plan, remember to avoid these five common training errors to increase your racing success.

1. Rapid Increase in Running Miles
A cold and snowy winter made winter running difficult in Missoula. A rapid increase in running mileage, however, is a fast track to developing a spring running injury. A 10% increase in weekly mileage is a tested rule of thumb to be followed. When mileage is increased too rapidly, fatigue sets in, running form is compromised, and injury risk increases. Log your running mileage and peel off from the group run if you are exceeding your 10% weekly running mileage.

2. Lack of Flexibility in Weekly Training Plan
Runners are inherently goal-oriented individuals. Therefore, successfully completing your weekly training schedule brings a sense of accomplishment. Experiencing an off day is a normal occurrence which should not be ignored. Fatigue, stress, poor sleep patterns, poor nutrition, and overtraining all contribute to having an off training day. If your body is not responding, modify your daily workout without guilt. If you missed a week of training due to prior commitments or illness, avoid the temptation to jump back in with the group. Allow room in your training plan for flexibility and your body will reward you with improved performance.

3. Ignoring Your Body’s Warning Signs
Most running injuries are related to overuse. Overuse, however, can be the result of overtraining, or a lack of strength necessary to run without compensations. If pain persists for more than 48 hours, seek medical attention which includes evaluating running biomechanics and determining the underlying cause of pain.

4. Running and Racing Injured
Although common sense tells us not run or race while injured, saying no is often the most difficult decision for a competitive runner. Race entry fees, travel plans, and sharing the race experience with friends and family are among the reasons many run and race injured. Rarely is the outcome positive and running or racing while injured only prolongs symptom resolution. A basic test is the 30-second hop test. If you can hop on a single (injured) leg without pain for 30-seconds, then initiating a return to running program is indicated. If you experience pain, then you are still injured and should rest, and work on strengthening any underlying weaknesses responsible for pain symptoms.

5. Neglecting Self Care 
Self care includes adequate sleep, proper nutrition, adequate rest days, rolling or massage, and strength training. Schedule self care into your weekly training plan. Contact Sapphire Physical Therapy for assistance in creating a strength training program and recovery routine to insure adequate stabilization and recovery necessary to run injury-free.
John Fiore, PT
Sapphire Physical Therapy
john@sapphirept.com
www.sapphirept.com
406.549.5283

Picture taken from Google images