The summer calendar is packed with races and runners are piling on the miles. Along with long runs and back-to-back workouts are running overuse injuries. Nearly 80% of runners sustain at least one overuse running injury per year.1 This month’s article will focus on the biceps femoris hamstring muscle. Biceps femoris tendinopathy (chronic inflammation and dysfunction of the tendon related to overuse) is a common, often misdiagnosed injury which plagues many runners.

The biceps femoris is one of three hamstring muscles. The biceps femoris is the lateral hamstring muscle and is composed of a short head and long head. The long head originates at the ischial tuberosity of the pelvis whereas the short head originates along the posterior portion of the femur. The short and long heads of the biceps femoris insert on the lateral knee (fibular head) and lateral collateral ligament of the knee. The biceps femoris flexes the knee, assists with knee extension, and the short head also externally rotates the tibia. Excessive biceps femoris use and deceleration (eccentric contraction) while running may lead to overuse and inflammation at the origin or insertion. Repetitive irritation due to excessive running or compensatory movement patterns (over-striding, glute/core weakness, poor core stabilization leading to anterior pelvic tilt) may lead to chronic tendinosis. Over-activation of the biceps femoris during hip extension results in less than ideal foot strike placement due to external rotation of the tibia. Repetitive “hamstring-dominant” running increases the risk of overuse injuries in the foot, ankle, knee, and hip by increasing torsional forces at foot strike and during the stance phase of the running stride.

Often misdiagnosed as iliotibial band friction syndrome, biceps femoris tendinosis must be treated through specific release techniques. The photo below demonstrates an effective dynamic release technique using a roll or ball beneath the distal biceps femoris while the subject slowly extends and flexes the knee. Following a period of manual therapy to release the hamstring, a glute, core, and eccentric hamstring strengthening program must be implemented for long-term symptoms resolution. Closed chain (weight bearing) double and single leg dynamic core, glut, and hip exercises must be included in an effective long-term hamstring strengthening program.

A physical therapist skilled in both therapeutic exercise and manual therapy is the person to evaluate and treat the cause of the pain. Manual therapy is a clinical approach using skilled, specific hands-on techniques to evaluate and treat joint structures and soft tissue restrictions for the purpose of reducing pain, increasing range of motion, reducing soft tissue inflammation, relaxing muscle guarding, improving stability through a joint, facilitating movement, and restoring function.2

Remember, regular strength training and adequate recovery are the best defenses against injury as the greatest predictor of future running injury is a history of prior injury.

John Fiore, PT
Sapphire Physical Therapy

Photo: Dynamic Release Biceps Femoris (

1 Van Gent RN, Siem D, van Middelkoop K, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. J Sports Med. 2007; 41:469-480. 2 Information on definition of manual therapy from American Academy of Orthopedic Manual Physical Therapy (AAOMPT). Accessed November 26, 2011.

Running is one of the most natural forms of human movement. The ability to run upright on two legs is rare in the world of mammals. Humans posses the combination of long, light bones propelled and stabilized by powerful gluts, quads, and hamstrings. Reciprocal lower extremity and upper extremity motion are made possible by our strong core musculature. Running injuries, however, sideline even the most experienced runners. The simplicity of running is dependent upon a complex sequence of mobility and stability through each of our lower extremity joints. This month I will focus on the ankle joint.

The ankle and foot absorb impact, allow our body to move from flexion (forward stride phase) to extension (propulsion phase), and keep us upright in the process. While extensive running injury prevention focuses on the hips, gluts, and quadriceps, the importance of the ankle is often overlooked. The trails on Mount Sentinel, Mount Jumbo, Blue Mountain, and the Rattlesnake are buff and smooth compared to many of the trails I have encountered while racing. A lack of adequate ankle mobility and strength will likely result in an ankle injury when running or racing on technical, rocky trails. Whether you run on the roads or on the trails, ankle mobility and strength must be incorporated into your training program.

The ankle is comprised of two main joints. The talocrural joint is formed by the tibia bone and the talus bone. The talocrural joint and its associated ligaments basically attach the lower leg to the foot. The surface of the ankle talus bone is smooth and shaped like a dome. The tibia bone glides over the talus, allowing us to pick our foot up, clear the ground, and push off. The subtalar joint is formed by the calcaneus (heel) bone and the bottom of the talus bone. The subtalar joint is responsible for balance reactions (lateral and medial) and provides stability on uneven surfaces. A comprehensive physical therapy evaluation by a therapist who understands the intricacies of the running stride can evaluate your ankle mobility as part of either a preventative consultation or to determine the underlying cause of pain. Inadequate ankle joint motion causes stiffness and increases compression through the ankle. While often not perceptible while running, prolonged ankle stiffness and compression increased the risk of osteoarthritis. If you have already been diagnosed with age-related or trauma-related ankle joint arthritis, reducing joint compression through mobilization can relieve your symptoms.

In order to strengthen the ankle, one must look at the foot and the lower leg (foot intrinsic strength and mobility are a topic for a separate article). The muscles which stabilize and guide the ankle are located on the anterior, posterior, and lateral aspects of the tibia bone. Four planes of motion (plantarflexion, dorsiflexion, inversion, eversion) which are crucial for efficient running must be strengthened both in isolation, and through functional single leg dynamic exercises.

Below are a few training suggestions to improve your speed and safety while running when the pavement ends and the trail turns into a ridge line. Theraband ankle strengthening is a good start, but incorporating ankle and foot specific single leg balance and mobility exercises in weight bearing will protect and prepare your foot ankle for running.

Single Leg Strengthening Exercises

Stand on one leg with your big toe planted into the floor. Engage your core (gluteal, abdominal, lumbar musculature) and use gravity with or without dumbbells, weight bars, a medicine ball, or a pulley system to teach your body to stabilize in a single leg position. Add dynamic partial squats, trunk rotation, and reaching motions for greater challenge.

Running Specific Agility Training

Moving lightly and confidently on your feet comes only with training. Set up an agility course inside or outside. Work on foot placement, accuracy, eyes open, and eyes closed.

Incorporate plyometrics and bounding in your agility training at a training heart rate.

Practice bounding uphill and rapid foot placement on technical terrain of varying gradients. Try running from rock surface to rock surface rather than avoiding rocks.

Relax when running on technical terrain and let your natural balance reactions and core strength do the stabilizing.

Foot and Ankle Mobility and Strengthening

Protect your lower leg, foot, and ankle from injury and overuse through proper conditioning. Ankle joint mobility is necessary for proper running mechanics and to reduce the risk of ankle sprain. Using a Theraband, move your foot/ankle inward with your toes relaxed and your ankle pointed downwards slightly. Next, move your foot/ankle outward against Theraband resistance with toes relaxed. Finally, pull your ankle upwards towards you with Theraband resistance.

For a comprehensive lower extremity mobility and strength evaluation to take your running to the next level or to address a chronic running injury issue, contact the Sapphire Physical Therapy.

John Fiore, PT
Sapphire Physical Therapy

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 Although spring is only three weeks away, the roads and foothill trails have thawed and the time has come for spring training. This year the inaugural Runners Edge Trail Race Series will provide a great opportunity to test your legs on four local race courses. Proper spring training will insure you reach the start line fit, fresh, and injury-free.

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 most common underlying cause of running injuries, however, is functional weakness of the hips and core which causes compensatory running form.

Stabilizing Excess 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. A physical therapist or trainer specializing in the treatment of runners can develop a program specific to your running needs.

Mileage Increases
Whether you are training for your first 10k or The Rut 50k, mileage increases must be incremental. The age-old 10% mileage increase per week rule is a safe and effective guideline. Gradually increasing 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. The net result will be fewer injuries and the ability to run with better form. 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).

Training Terrain
Unlike the 10% rule for increasing weekly mileage, different races warrant different training terrain. I am often asked how many miles I run per week. While mileage is important to track, the time on your feet and the elevation or vertical climbed is of greater importance for trail runners. Many trail ultra races have upwards of 10,000-30,000 feet of vertical gain. Factoring equally time on your feet (hours), vertical (elevation climbed), and miles run in training will give you a gauge of how you will do on race day. Simulate the terrain of your race while training. Practice your race pace (which may require slowing down if your race is an ultra) and don’t forget to include a shorter, high-intensity workout simulating race terrain once or twice per week. Running cadence, running light on your feet, and nutrition on the move should all be included in your training runs.

Listen to Your Body
Most of us follow a weekly training routine to prepare us for our goal race(s). 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.

Sapphire Physical Therapy is here to help you reach your 2016 running goals. Call us or email your questions and I will respond to your within 24 hours.
John Fiore, PT

Sapphire Physical Therapy

Image credit:
1 2 Van Gent RN, Siem D, van Middelkoop K, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. J Sports Med. 2007; 41:469-480. 3 Ballas M, Tyrko J, Cookson D. Common overuse running injuries: Diagnosis and management. Am Fam Physician. 1997: 55(7):2473-2484.

Running without injury to achieve one’s fitness, training, and/or racing goals is the predominant objective of runners. It is important to filter training and treatment fads to understand the true reason runners get injured. Why do some runners get injured while others following an identical training plan do not? The answer lies in observing key movement patterns and asking the right questions.

Simple movements such as walking, running, skiing, reaching, and throwing are comprised of movement patterns we learn at a young age.
Movement patterns allow us to move efficiently and repetitively. Factors such as lifestyle changes (prolonged sitting), repetitive motion, muscular weakness, postural changes, prior injury, and range of motion limitations change our movement patterns. These changed movement patterns, which we often do not recognize in ourselves, create compensatory or synergistic movement imbalances. Our risk of injury (micro-trauma, overuse, sprain/strain, pain) increases in the presence of compensatory movement imbalances.Unless a physical therapist screens for addresses movement imbalances, injury treatment will ineffective in the long run.

Understanding a few facts regarding how our bodies move is an important first step in understanding and treating movement imbalances. Skeletal muscle can be divided in to two groups representing their primary function: Stabilizers and Mobilizers. S
tabilizing muscles allow us to maintain the posture necessary for movement. Diminished stabilizing muscle activation leads to movement imbalances and overuse injuries in the lower extremities. Stabilizing muscles (which all runners should work to strengthen) include the gluteus medius, transversus abdominus (lower abs), obliques, lower trapezius, serratus anterior, multifidus (deep low back muscles), rotator cuff, and deep neck flexors. Mobilizing muscles are more familiar to us as they are responsible for moving our extremities: Quadriceps, hamstrings, gastrocnemius, hip flexors, adductors, rectus abdominus (six pack muscle), erector spinae, and latissimus dorsi. In the presence of muscle shortening (secondary to frequent sitting, postural tightness), prior injury, weakness, or repetitive motion activities (involved in single-sport training such as running) stabilizing muscles are inhibited unbeknownst to the individual. For example, in the lower extremities, the stabilizing gluts and abdominals are often inhibited and overpowered by the hamstrings, hip flexors and quadriceps.

A movement imbalance example common in both recreational and competitive athletes is that of hip extension.
The ideal muscle firing pattern for proper hip extension is stabilization of the low back with the multifidus and transversus abdominus, extension of the leg with the gluteus maximus, and secondary assistance with the hamstring. A common compensatory movement imbalance for hip extension is contraction of the erector spinae and hip flexors, extension of the leg with the hamstring, and little or no contraction of the gluteus maximus. If such a compensatory hip extension movement pattern is not changed through training, even the most progressive strengthening program will not protect a person from injury or allow him or her to return to running following an injury.

Don’t waste your training time by strengthening compensatory movement patterns which lead to injury! Get the most out of your training through an effective physical therapy consultation.The physical therapy staff understand synergistic compensation patterns which lead to movement imbalances and injury. For more information, call or email the Sapphire Physical Therapy staff. Make 2016 the year you run, train, and compete without pain or limitations. Move well, be well!
John Fiore, PT
Sapphire Physical Therapy