Proximal Hamstring Pain in Runners

By:  John Fiore, PT

The hamstring is an important and complex muscle group used in running. While minor hamstring pulls and strains are fairly common in runners, proximal hamstring overuse injuries can be very debilitating. Repetitive micro-trauma in the hamstring attachment site (ischial tuberosity of the pelvis) may result in proximal hamstring tendinopathy (acute tendinitis or chronic tendinosis). While proper diagnostic testing is key (clinical testing by an experienced physical therapist, real-time ultrasound by a sports physician), insufficient or incorrect treatment of proximal hamstring tendinosis can shut a runner down for months.  

Understanding the hamstring musculature is the first step.  Unlike most muscles in the human body, the hamstring crosses two joints (hip and knee) and plays a role in two distinct movements. The hamstring’s primary function is to flex or bend the knee. If your knee bends, you can thank your hamstring for its work. 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.  Understanding the hamstring is the first step in preventing and treating hamstring related running injuries.

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 a proper treatment progression is crucial. Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are strong 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. You can go to the gym five days a week and do hamstring curls to strengthen your hamstrings but continue to have pain while running. The key to effective treatment lies in understanding the hamstring’s role while running. A video running analysis is a helpful way to detect underlying running compensations and cadence which may influence running stride which increases hamstring stress.

A qualified physical therapist skilled at applying pain-relieving modalities, integrated dry needling, deep tissue release-mobilization, muscle energy techniques to balance pelvis symmetry, active release techniques, and contract-relax techniques will address pain and tissue restriction in the hamstring secondary to overuse. An eccentric hamstring strengthening program based on your pain, compensations, and goals will build tensile strength in your hamstring and tendinous attachments. Ruling out underlying pathology (such as lumbar spine referred pain) is important as well. Finally, do not forget to roll, release your hamstrings to decrease muscle and tendon tension. A few exercise examples are illustrated below, but see a qualified physical therapist to rule out underlying injuries,  referred pain, and for the gradual addition of strengthening exercises when appropriate. Call or email John, Holly, or Jesse at Sapphire PT with any questions or to schedule a consultation (406-549-5283 or 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 or low back to sway-collapse.
  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.

  6. TRX hamstring curls: Lie on your back with heels hooked in TRX loops. Contract your glutes and raise your hips-pelvis off the ground. Slowly bend your knees and slowly return to a straight-knee position. Lower hips-pelvis to the floor and repeat.

Photo: www.strengthperformance.com

 

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.

 

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Winter Off Season Training: Gaining Fitness, Strength, and Durability

As snow begins to accumulate in the mountains surrounding Missoula, many runners long for the warm and sunny days we have become accustomed to over the past several months. Winter, however, provides a crucial opportunity to improve your overall health as a distance runner. Repeating the cycle of training-racing-recovering over several months takes a toll on the body. Consider complimenting your winter running with one of the many winter sports available to Montanans. Not only is winter cross training therapeutic, but it is fun as well. Introducing new movement patterns and loads will allow your bones, muscles and connective tissue to rebuild, providing long-term durability for the 2019 running season. Fitness is comprised of strength, mobility, aerobic conditioning, and power. While running is required to gain running fitness, it is important to gain strength, mobility, aerobic conditioning, and power to maximize running fitness. Winter is the time to train your weaknesses, not your strengths.

 

Strength training should be part of every off season plan for runners. 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 (Powers C. J Orthop Sports Phys Ther 2010;40(2):42-51. doi:10.2519/jospt.2010.3337). A strength training program aimed at providing functional stabilization of the hip and pelvis in multiple planes is, therefore, a vital part of any off season strengthening program. As we grow older, muscle strength becomes more important as we lose approximately 1% of our muscle mass every year. More importantly, the decline in muscle strength declines at a rate 3-times greater (Goodpaster, B.H., et al., The loss of skeletal muscle strength, mass, and quality in older adults: the health, aging and body composition study. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 2006. 61(10): p. 1059-1064. https://www.ncbi.nlm.nih.gov/pubmed/17077199). Body weight strengthening is important if you are new to weight training or have a history of joint issues. To build muscle strength and durability, however, resistance training (bands, free weights, kettle bells) is necessary. Care should be taken to seek advice of a physical therapist or a personal trainer to assess your strength training technique. One muscle group many runners overlook are the calves (gastroc-soleus muscles). Between the ages of 20 and 60, runners typically experience a 31% reduction in ankle power, total power (ground reaction force to lift you off the ground and in a forward direction), along with a 13% decrease in stride length and running speed (DeVita P, Fellin RE, Seay JF. The relationship between age and running biomechanics. Med & Sci Sports & Exerc. 2016; 48 (1): 98-196.). Performing calf raises-drops and single leg hops will target the calves. Remember to slow down during weight training repetitions to maximize strengthening benefits. Two to three strength training sessions per week will compliment your winter outdoor activities.

 

Mobility becomes more elusive as we age. Runners are particularly vulnerable to stiffness in the knee, hip, and ankle joints as we move in only one plane. Addressing mobility restrictions with the help of a physical therapist will decrease your osteoarthritis risk and improve your running efficiency. Winter is the time to attend a yoga class, seek stretching advice, and have your running stride analyzed to decrease joint loading to promote joint health.

 

Aerobic conditioning requires consistent work. Experience has taught me that maintaining a base level of cardiovascular fitness in the offseason reduces the need to play “fitness catch-up” in preparation for spring running and racing. Building your aerobic engine to carry you up climbs both short and long requires specified training. High intensity intervals are never fun, but mixing it up the means by which you subject yourself to intervals reduces burn-out. Nordic skiing intervals, skinning (backcountry or ski mountaineering set-up) intervals, power hiking intervals, and cyclocross racing are great ways to disguise intervals in a fun and novel activity. One to two longer running or snow hiking workouts in your aerobic threshold range will build or maintain your aerobic fitness.

 

Photo courtesy of stretchcoach.com

Power is achieved through explosive movements such as plyometric exercises and through interval training. Short intervals included in a workout 1-2 times per week will provide the acceleration a summer of long miles has taken away. Utilize a watch timer and heart rate monitor to gauge effort. Plyometric exercises include a loading phase followed by a propulsive unloading phase. Plyometric exercises should not be done when sore or injured, and an adequate level of strength is necessary to perform correctly. Again, seek advice from a physical therapist or personal trainer prior to adding power training to your off season program.

 

Motivation becomes challenging as the daylight hours shrink and the temperatures drop. To avoid runner’s burnout, reduce your winter mileage and intensity and shift your focus on the exercise suggestions outlined above. Embrace the season and find an outside activity or sport which is intriguing. I discovered backcountry skiing and randonee or ski mountaineering two years ago. A January-March Thursday night race series (Rando Radness) at Montana Snowbowl which is organized by Mike Foote attracts skiers of all ages and abilities in a fun, social atmosphere. The winter days of riding my bike on a trainer indoors are long gone.

 

Durability will reduce injury risk by preparing your body for the demands of the running season. Overall fitness (strength, mobility, aerobic conditioning, power) combined with reasonable training volume increases and adequate recovery determine one’s long-term running durability. The off season is the time to build running durability as distance running and racing have a catabolic (breaks down tissue) effect on body tissues. Make the coming winter a season full of adventure, recovery, rebuilding, and fun.
John Fiore, PT
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Fitness and Aging: Filtering Through Facts and Misinformation

True: Aging impacts my health and fitness. False: Maintaining fitness is not possible since I am over 40 or 50 or 60 or 70 years old. A September 2018 article in Readers Digest listed 13 exercises one should avoid if he or she is 50 years old. Yes, this caught my attention as I endorse every one of the 13 exercises if done correctly. While I do not consider Readers Digest as a credible source for exercise and fitness news, I will list the 13 exercises, all of which have benefits if done correctly:
1.Running Stairs
2.Spin Classes
3.High Intensity Interval Training
4.Hot Yoga
5.Push-ups
6.Squats with Weight
7.Bench Press
8.Burpees
9.Pull-ups
10.Crunches
11.Dead Lifts
12.Jumping Lunges
13.Sprints
The degree to which fitness is impacted by aging is based on physiology, genetics, medical history, exercise choices, and lifestyle choices. The largest factor influencing fitness as one ages (insert your definition of what “aging” represents), however, is lifestyle choices.Physiological changes associated with aging include a change in cardiac function (i.e. Max heart rate, cardiac output), a decrease in lean muscle mass, a decrease in strength, a
decrease in flexibility, a decrease in connective tissue elasticity, and a decrease in bone density. Genetics also plays a large role in the physiological cards we are dealt at an early age. Joint stiffness in the spine may be virtually absent to some, while others may develop a more limiting genetic form of spinal degeneration such as ankylosing spondylitis (HLA-B27). 1 Prior medical history and orthopedic injuries (joint and ligament injuries, fracture history, overuse injury history, bone density baseline) should guide the degree of impact your body will tolerate during exercise. But what about the factors each and every one of us can influence regardless of our genetics? How is one to sort through the conflicting information available on the subject of fitness and aging? Understanding your present fitness, fitness goals, and recognizing your past and present medical issues will guide lifestyle fitness choices to allow you to maintain fitness for years to come.
As a physical therapist and an endurance athlete, I view proper exercise as the most effective way to positively influence fitness with age. I quantify this statement with the words proper exercise because many factors determine how well your body will respond to certain exercises. Running is a relatively high impact form of exercise. If done correctly (efficiently and following a consistent, gradual training program), however, running may be tolerated well into one’s 60s and 70s. Exercise consistency is crucial for life-long fitness. Regular exercise (3 days per week minimum with 5 days per week preferred) must address the areas of fitness most impacted by age. Strength training must be included as physiology has shown a decrease in lean muscle mass and strength naturally occurring with age. Speed must be included as our fast twitch (speed) muscle fibers are replaced by slow twitch (endurance)muscle fibers with age. Flexibility training must be included to promote joint health and reduce osteoarthritis, and cardiovascular exercise must be included for circulatory health and to maintain a healthy body weight. To reduce joint-related pain, minimize impact loading and vary your workout routine accordingly.
So what is the magic exercise? What is the key to fitness with age? Where do I buy the DVD or infomercial product to give me life-long fitness? No single exercise exists which combines all of these necessary components into one activity. Training, therefore, begins with finding an exercise form you enjoy (i.e. running, cycling, swimming, skiing). The next step is to develop a functional strength training program (with the help of a qualified physical therapist or trainer) aimed at improving your power and efficiency. Add to your
strengthening program a dynamic stretching program to insure healthy joint motion and mobility. Mix up your workouts to decrease the adaptation effect created in the body when you run the same 4-mile loop every day. Finally, have an annual physical to make sure your heart is healthy, your blood levels are within normal limits, and your cholesterol and blood pressure are normal.
Fitness beyond the 20s and 30s has many faces. From the person who has just been told by their physician to lose weight and reduce their blood pressure to the 60-year old athlete who defies both years and gravity, fitness in the second half of life does not have to be elusive. Life
experiences, life choices, environmental factors, genetics, and dedication to health and fitness all impact our fitness later in life. Call Sapphire PT to find out more about how you can realistically attain your fitness goals at any age.
1 Brown MA et al. Clin Exp Rheumatology; 2002. 20: S43-S49.
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Ankle sprains are one of the most common injuries experience by trail and mountain runners due to the steep and uneven terrain. Ankle sprains, however, are not all alike. In last month’s Runners Edge Newsletter, lateral ankle sprains were discussed. Most of the athletes treated for ankle sprains at Sapphire Physical Therapy participate in activities which involve running, jumping, sprinting, skating, or sliding into base. Many of these individuals present with some degree of high ankle sprain. This vague and general term warrants explanation for effective treatment and timely return to activities.

The anatomy of a high ankle sprain involves four main ankle ligaments (see illustration) plus one often forgotten structure: the syndesmosis or interosseous ligament. The syndesmosis ligament provides stability for the movement of the tibia and fibula as a unit over the talus bone of the ankle. Normal widening or splaying of the tibia and fibula is only 1 mm thanks to the syndesmosis ligament.

*Photo credit: Browner B, Jupiter J, Levine A, Trafton P: Skeletal Trauma: Fractures, Dislocations, Ligamentous Injuries, ed 3. Philadelphia, PA, Saunders, 2003, vol 2, p 2307-2374.)

High ankle sprains are familiar to runners as well as soccer, lacrosse, and hockey players. What makes high ankle sprains difficult to diagnose and treat is the fact that most ankle sprains are minor and heal following several days of rest and conservative treatment. When the syndesmosis ligament is strained, however, pain, stiffness, and poor weighe bearing tolerance persists. When the syndesmosis ligament complex is suspected due to a high ankle sprain, specific testing should be conducted for effective treatment.

The syndesmosis ligament complex is often strained secondary to high impact, forced dorsiflexion (foot bent upward) combined with an eversion (inside of foot rolls outward) sprain. A sudden, high velocity ankle roll with impact sufficient to force the foot in an upward motion which increases the widening or splaying between the tibia and fibula bones. The deltoid ligament may or may not be involved in a high ankle eversion sprain as well. Swelling may or may not be present, and syndesmotic sprains characteristically do not get better on their own. Athletes commonly express frustration due to the fact that rest, ice, elevation, and an over-the-counter ankle brace did not allow them to return to running or sport. Sources place the frequency of ankle syndesmosis injuries at 1% to18% of all ankle sprains. In athletes and runners, however, the incidence increases to 12% to 32%.

Fractures should be ruled out in the case of a high ankle sprain. If swelling subsides within two days and weight bearing becomes pain-free, then an X-ray may not be indicated. If symptoms of swelling, pain, and difficulty weight bearing persist, then an X-ray is indicated. Magnetic resonance imaging (MRI) may be indicated if a syndesmotic injury is suspected. Research has shown X-rays to be less accurate (44% to 58% specificity) than MRI (nearly 100% specificity) in diagnosing a syndesmosis ankle sprain component. The degree of tibia-fibula gapping or splaying (positive when greater than 1 mm lateral subluxation or greater than 5 mm separation between the distal fibula and tibia) and the stability of the ankle (presence or absence of additional ankle sprains, stability, or fracture) will determine whether conservative treatment or surgery is the best course of action.

Treatment: Ankle inflammation reduction and rest, followed by progressive mobility and stability are necessary for proper ankle rehabilitation following an ankle sprain. If a fracture is present, then the treatment progression will occur secondary to fracture healing which is usually 6-8 weeks. A high ankle sprain involving the syndesmosis ligament requires stabilization for pain-free weight bearing activities prior to returning to running and sports. If the correct conservative treatment measures fail, surgery may be necessary. The treatment techniques described below, therefore, should be done only after a thorough evaluation including clinical and diagnostic testing.

Taping: Some degree of syndesmosis ligament stabilization is possible with taping. A physical therapist with experience treating high ankle sprains should apply the taping techniques described below:

The distal tibia and fibula must be taped circumferentially with a strong, non-stretch, durable tape. I use a base tape to protect the skin followed by strips of Leukotape. Pain reduction should be >50% with tape applied to allow for walking without a limp. Return to activities and exercise should occur only if taping provides pain-free weight bearing. I also utilize the Mulligan high ankle sprain taping technique to stabilize the lateral ankle ligaments and tibia-fibula joint.

Braces: A walking boot may be necessary to allow for early mobility following an ankle sprain. If pain is too great to allow for weight bearing without a walking boot one week following a high ankle sprain, diagnostic testing is warranted. A soft Velcro ankle brace (referred to as an ASO brace) will provide some ankle support but will not stabilize the syndesmosis ligament.

Range of motion, strength and balance: Pain-free ankle active range of motion is the necessary first step in treating a high ankle sprain. Once full pain-free motion is achieved, lower leg, foot, and hip strength must be evaluated and addressed. Restoring single leg balance and proprioception (positional body awareness) will reduce ankle sprain re-injury risk. Research has shown heightened ankle sprain risk in the presence of limited dorsiflexion range of motion, reduced proprioception, and decreased single leg standing balance. Restoring ankle range of motion and strength is followed by gradually adding in weight bearing static and dynamic exercises. Post-high ankle sprain rehab culminates with agility and balance drills specific to your sport or activity goals.

 

  1. Hunt KJ, Phisitkul P, Pirolo J, Amendola A. High Ankle Sprains and Syndesmotic Injuries in Athletes. JAAOS 2015 Nov;23(11):661-673.
  2. Mak MF, Gartner L, Pearce CJ. Management of syndesmosis injuries in the elite athlete. Foot Ankle Clin N Am. 2013;18(2):195–214. 
  3. Waterman BR, Belmont PJ, Jr, Cameron KL, Svoboda SJ, Alitz CJ, Owens BD. Risk factors for syndesmotic and medial ankle sprain: role of sex, sport, and level of competition. Am J Sports Med. 2011;39(5):992–998.
  4. de-las-Heras Romero, J., Alvarez, A. M. L., Sanchez, F. M., Garcia, A. P., Porcel, P. A. G., Sarabia, R. V., & Torralba, M. H. (2017). Management of syndesmotic injuries of the ankle. EFORT Open Reviews, 2(9), 403–409. http://doi.org/10.1302/2058-5241.2.160084
  5. Vuurberg G, Hoorntje A, Wink LM, et al. Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline Br J Sports Med 2018;52:956.
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Treat Your Feet to Reduce Spring Injury Risk

By John Fiore, PT
The spring running season is underway. With Runner’s Edge Events Trail Series and Run Wild Missoula races taking place nearly every weekend, now is the time to treat your feet to reduce injury risk. The human foot is comprised of 28 bones and their associated ligaments, tendons, and muscles. This month’s article will focus on the plantar fascia which plays a large role in the Windlass Mechanism which improves intrinsic foot support. Spring is the season when plantar fascia injuries increase. Early treatment is key to avoid season-ending pain.
The plantar fascia is a thick fibrous band of connective tissue which runs from the front of the calcaneus (heel bone) to the base of the toes. It acts as a last resort to stabilize the longitudinal arch of the foot. Characterized by pain in the heel region of the arch of the foot,

 

plantar fasciitis is the the most common cause of heel pain requiring medical care. It is estimated that 1 in 10 people will develop plantar fasciitis in their lifetime, resulting in one million visits per year to medical visit annually. Because plantar fasciitis is often a chronic condition, understanding the causes and treatment options will lead to effective resolution.
Plantar fasciopathy is a more accurate term to describe heel and arch pain as it includes the inflammatory condition (plantar fasciitis), and degenerative condition (plantar fasciosis) of the plantar fascia. Plantar fasciitis occurs when the thick, fibrous plantar fascia becomes inflamed due to poor foot strength, repetitive arch strain, or faulty foot-ankle biomechanics. Plantar fasciosis describes the non-inflamed degenerative state of the plantar fascia due to repetitive stress.
Diagnosing plantar fasciitis involves palpating its attachment on the front of the calcaneus (heel bone). Pain is experienced during prolonged standing, running, descending stairs, and most notably upon rising and walking across the floor first thing in the morning. Additional causes of heel and plantar pain to be ruled out by your physician or physical therapist include bone stress reaction, stress fracture, localized nerve entrapment, lumbar S1 radiculopathy. Predisposing factors to plantar fasciitis include repetitive impact (distance running, jumping), rapid increase in activity level or mileage, poor intrinsic foot-ankle support, poor running biomechanics, and obesity (BMI >30).
Effective treatment of plantar fasciopathy includes four phases:
Acute Pain Phase: During the acute pain phase, pain must be reduced by avoiding running or prolonged standing, support through taping, anti-inflammatories (if inflammation is present), and reducing impact through gel heel cup and comfortable footwear. Isometric toe flexor exercises, active stretching techniques for the plantar fascia and gastroc-soleus muscle group will improve foot and ankle function.
Gradual Loading Phase: Manual physical therapy, progressive lower leg and ankle resisted exercises are added during this phase, and underlying hip, glut, and core weaknesses are addressed. Gradual plantar fascia loading exercises begin with double leg heel raises followed single leg heel raises as tolerated.
Heavy Loading Phase: Once single leg heel raises are tolerated pain-free, a barefoot modified (towel roll beneath toes) single leg calf raise progression is commenced. The Rathleff loading program (Rathleff et al 2014) continues to add resistance to single leg heel raise progressions over four weeks, building eccentric strength and tension tolerance. Running is reintroduced upon successful completion of the Rathleff program. A 2D video running analysis is vital to insure proper running biomechanics to reduce re-injury.
Successful long-term return to distance running requires regular plantar fascia release, foot intrinsic strength, and lower leg mobility and strengthening exercises. Proper footwear, adequate recovery following exercise, and gradual increases in training load will help keep plantar fasciitis and other foot issues from returning. The experts at Sapphire Physical Therapy can evaluate your running gait, detect any form or strength issues, and develop a foot injury prevention and treatment program to meet your individual needs. Call Sapphire Physical Therapy, (406) 549-5283, or learn more at www.sapphirept.com and don’t let your feet keep you from meeting your spring running goals.
1.Riddle DL, Pulisic M, Pidcoe P, Johnson RE. Risk factors for plantar fasciitis: a matched case-control study. J Bone Joint Surg Am. 2003:85-A:872-7
2 Riddle DL, Schappert SM. Volume of ambulatory care visits and patterns of care for patients diagnosed with plantar fasciitis: a national study of medical doctors. Foot Ankle Int. 2004 May. 25(5):303-10
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Reducing Spring Overuse Injuries: A Closer Look at Posterior Tibilias

     Warmer spring temperatures and upcoming races mean longer runs and an increased risk of overuse injuries. Spring is common time for overuse injuries to the tibialis posterior muscle as it’s function in vital to efficient running. The tibialis posterior is a small, thin, unassuming muscle which plays a vital role in walking and running locomotion. Located on the posterior aspect of the lower leg, the tibialis posterior is deep to the easily recognizable calf musculature (gastroc-soleus muscle complex). The tibialis posterior originates on the posterior side of the fibula and tibia, and inserts on the navicular, second cuneiform, and 2nd , 3rd , and 4th metatarsal bones of the foot. Tibialis posterior weakness or injury can sideline even the most seasoned runner. Evaluation of strength and functional activity is vital to properly detecting tibialis posterior dysfunction.
     The function of the tibialis posterior is much more important than its diminutive presence in the lower leg. It acts to invert (turn inward) the foot and ankle, supinate the foot (raises the arch) and aids in dorsiflexion (upward motion of the foot) of the foot and ankle. Without the tibialis posterior, the stability of the foot and ankle is compromised significantly during walking and running. Consider for a moment a flat foot. The term flat foot has a negative connotation, but pronation (or lowering of the arch of the foot) is necessary to absorb
shock and accommodate to uneven surfaces. Supination, however, is necessary to bring a pronated, flat foot into a position of stability for push-off while walking or running. Efficient, pain-free running is dependent on the ability of the tibialis posterior to bring the foot and ankle into a supported position (through supination). Without the action of the tibialis posterior, the foot and lower leg are subjected to increased tensile strain during the stance and push-off phases of gait. Injuries such as plantar fasciitis, medial tibial stress syndrome (shin splints), knee pain, hip pain, iliotibial band pain, and even low back pain can often be traced in whole or part to a deficient or weak tibialis posterior muscle.
     Prevention and treatment of tibialis posterior dysfunction begins with body awareness and smart training habits. Tibialis posterior specific strengthening exercises include heel raises with slow lowering to the ground. Adding mild inversion as you lower your heel to the ground will bias the tibialis posterior. Band resisted ankle inversion with the ankle in plantarflexion will strengthen the tibialis posterior in non-weight bearing. Gradually increasing your mileage and easing into rough trail terrain will reduce overuse injuries in the tibialis posterior as well. If your calves or feet are tired or painful after running or weight bearing exercise, allow your body to rest, and recover for 1-3 days. If you continue to experience pain after 3 days a physical therapy evaluation may be indicated. Your physical therapist will rule out injuries such as a stress fracture, sprain, strain, compartment syndrome, or circulatory issues for which you will be referred to your physician for diagnostic testing. If the physical therapy evaluation is negative for serious injury, a Sapphire PT physical therapist will test for underlying weakness and-or inflammation responsible for your symptoms. Understanding the mechanics of walking and running and the contribution of other factors such as hip and core strength and running technique will narrow the treatment plan to a concise set of rehabilitative and preventative exercises. Your physical therapist will also guide you in a progressive return-to- activity plan based upon your response to PT treatment. The take home message is to take action when foot or medial ankle pain limits your ability exercise.
John Fiore
Sapphire Physical Therapy
john@sapphirept.com
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