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 Fiore, PT

The strongest predictors of running injury include a prior history of running injury, running throughout the year without a break, and a rapid increase in running mileage of >10% per week (Br J Sports Med 2007). Identifying compensatory movement patterns through a comprehensive running evaluation identifies underlying faulty biomechanics and strength deficits.

The January partial thaw is behind us and many Missoulians are anxious to hit the roads and trails. The race season arrives early in mountain towns such as Missoula. Before ramping up your weekly running mileage, however, consider the importance of improving the efficiency with which you run. Once reserved for elite athletes and research subjects alone, state of the art running analysis is available in Missoula.

Sapphire Physical Therapy provides on-side real-time 2D running gait analysis. We are excited to share this informative, interactive, diagnostic technology with the Missoula running community. LED markers and high-speed cameras provide real-time feedback for both the runner and the physical therapist. Sapphire Physical Therapy uses the Simi Aktisys 2D system. Developed in Germany, the Simi Aktisys software records joint angles along the frontal, posterior, and sagittal (side) planes of motion as a person runs. Planes of movement and joint ankles (ankle, knee, hip, trunk) are recorded and observed as a person runs. The software analyses the measured video data and an easy to read, usable PDF report is produced for the runner and physical therapist. Utilizing 2D video running analysis during a physical therapy evaluation takes the guesswork out of determining the underlying cause of movement inefficiency and/or injury.

In addition to our 2D video running analysis system, we now offer provide a dynamic accelerometer evaluation which can be done simultaneously. Accelerometer date includes foot strike pattern, cadence, step length, impact force (measured in Gs of force), braking force, pronation angle, and pronation velocity. Asymmetries identified through accelerometer measurements are used in conjunction with visual video analysis to modulate impact forces and reduce future injury risk. Real world accelerometer data may also be collected during outdoor running session on the roads of trails. Following a run, the subject’s data can be downloaded to our computer and viewed for practical running analysis feedback.

Once a compensatory movement pattern is recorded, the runner can return to the treadmill (or roads-trails in the case of an accelerometer evaluation) and make changes in his or her running mechanics while observing themselves in real-time on the monitor screen. Individualized exercises addressing observed compensations or weaknesses address the cause of observed compensations to improve running efficiency. Walking biomechanics is fairly universal in healthy individuals, but running biomechanics is diverse and very difficult to accurately assess visually or with a hand-held video device in one plane. The Sapphire Physical Therapy staff looks forward to helping Missoula runners improve their running efficiency and determining the underlying cause of recurrent injuries.

Cost for a 2D video running analysis with accelerometer evaluation is $150.  The hour-long appointment includes filming, review of video data, PDF printout, a discussion of possible compensations impacting biomechanics, and individualized exercise and treatment recommendations. Call Sapphire Physical Therapy (406-549-5283) to schedule your video running analysis or email me (john@sapphirept.com) for additional information.


John Fiore, PT

(Should runners stretch and if so how?)

John Fiore, PT


Confusion and controversy exists regarding the proper way for runners to stretch. Some runners stretch regularly while some never stretch at all. Stretching confusion originates in choosing the most effective way to stretch. Should I stretch to reduce injury risk? Will stretching help or hurt my running performance? What muscle(s) if any should I stretch?  Understanding the difference between static stretching and dynamic stretching as well as when to utilize each is an important first step in developing an individualized stretching routine to meet your running goals.

Athletes generally stretch before or after training and competition because we were once told we should. Historically, stretching routines were fairly universal for athletes regardless of body type or sport. Research has shown, however, that static stretching warm-up routines actually decreases athletic performance while a dynamic stretching warm-up routine improves performance by decreasing injury risk (Perrier ET, Pavol MJ, Hoffman MA. J Strength Cond Res. 2011 Jul:25(7):1925-31 & J. Wilson, PhD; Journal of Strength and Conditioning).  

Here are some great dynamic stretches for runners.

Static stretches for runners include calf, hip flexor, quadriceps, and iliotibial band stretches.  Typically held for at least 60-seconds, the purpose of static stretching is to increase flexibility.  Static stretching targets collagen (the main component of tendons and connective tissue such as fascia) elasticity as well as muscle length. The problem with static stretching as a warm-up routine is two-fold. Increasing the length of a muscle or connective tissue in the body is a long-term commitment. Stretching statically for 60-seconds prior to a run or race will not result in long-term effects. The time to do a static stretching routine is after your run or race is over, or when your body is at rest. Static stretching requires a time commitment, but can be an effective means of reducing injury if done properly. Static stretching has an inhibitory neuromuscular effect on the body. Research has shown that a statically-stretched muscle produces less force for up to an hour following static stretching.

In contrast, dynamic stretching involves active movement of a limb (and the associated muscles and joints) associated with running prior to training and racing to prepare the body for movement. Dynamic stretching positively influences the neuromuscular component of running-specific muscles. Within the muscle-tendon junction of our lower extremities are structures called Golgi tendon organs. The Golgi tendon organs monitor muscle tension during activity and trigger the body’s protective mechanism of guarding or co-contraction to decrease injury risk. Dynamic stretching as a warm-up prior to activities such as running has been shown to inhibit the reactivity of the Golgi tendon organs. Targeted muscle contraction during dynamic stretching has a positive effect on the Golgi tendon organs.  The net result of dynamic warm-up is a body with a short-term, functional increase in muscle length without the strength inhibition characteristic of static stretching.

A dynamic warm-up routine for runners should target the hips, quadriceps, hamstrings, gluteals, gastroc-soleus, intrinsic foot musculature, and upper body-torso. Dynamic warm-up is simple, requires no equipment, can be done wherever you are. To summarize, the goal of a pre-running dynamic warm-up routine include: Moving the joints, warming up the musculature for running, and decrease the body’s resistance (protective guarding) to intense or sustained activity through dynamic stretching.

John Fiore, PT


Addressing Age-Related Calf Weakness

An average weekend in Missoula, Montana confirms the fact that 30 million people ran at least 50 days annually in the United States in 2012-2013. Running efficiently and injury-free, however, is more elusive. Nearly 79% of all runners experience a running injury annually. As runners age, the primary site of overuse injuries changes from the knee to the Achilles, ankle, and calf. Both observation (on the roads, trails, and in our running lab) and research correlates the increase lower leg injuries with altered running biomechanics and reduced calf muscle power measure as ground reaction (vertical) force.

Despite our best efforts to train consistently, understanding what happens to our running stride as we grow older allow us to focus our efforts on targeted lower leg strengthening to reduce injury risk and maximize running performance. A September 9, 2015 article in the New York Times brought to the forefront the work of Paul DeVita, a professor of kinesiology at East Carolina University in Greenville, N.C., and president of the American Society of Biomechanics.  Dr. DeVita’s 2016 research looked at running gait changes in a sample of 110 runners. The runners were a mix of male (54%) and female (48%) who had been injury free for at least 6 months. The age range was 23-59 years old. DeVita and his colleagues found that the older runners ran with a shorter stride length, a higher turnover (cadence) rate. The net result is a slower running pace which research has shown is due to altered running mechanics, decreased calf-lower leg muscle strength, and increased stiffness in the ankle with age. 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.

The statistics referenced above should be strong motivators to masters and young runners alike to be proactive with targeted strength training, especially in the off-season. With much of the mainstream running injury reduction focus targeted on foot strike pattern and core strength, the importance of the calf musculature (gastrocnemius, soleus) is often overlooked. Ankle stiffness predisposes one to developing further calf weakness. The calf muscle aids in initiating the push-off phase of the running stride, and plays a key role in absorbing impact as your foot hits the ground. The importance of the calf muscle in absorbing impact loads is phenomenal: 160-180 foot strikes per minute with 2.5 times your body weight plus the force of gravity exerted through each foot strike over “x” number of minutes running equals a HUGE demand placed through the foot and lower lower leg. Eccentric (resisting gravity) calf strengthening will increase the resilience and shock absorption properties of your calf musculature, while concentric (against gravity) and plyometric strengthening will increase the power generation of your calf muscle.

To summarize, DeVita’s research confirmed running stride length, speed, and lower leg muscle function decline in a linear manner with age.  Calf (gastroc-soleus muscle) and ankle strength declines with age as well.  A reduction in lower leg muscle strength (both concentric and eccentric) and ankle motion (dorsiflexion) shifts the burden of self-propulsion to our knees, hips and gluts which are already physically challenged by prolonged sitting and tight hip flexor muscles. Lower leg, foot, and Achilles tendon injuries become increasingly common in runners over forty. Gradual degradation of muscle and tendon tissue integrity and nerve innervation sets the stage for an increase in running-related overuse injuries. Stretching the calf and lower leg muscles, Active Release techniques, dynamic warm-up, and rolling are great ways to improve lower leg muscle tissue mobility. Lower leg, ankle, and foot strengthening exercises must be a part of every runner’s training program, not just those in the fourth decade of life and beyond.  Strengthening exercises should include single leg heel raises, heel drops, resisted ankle inversion, eversion, dorsiflexion, and intrinsic foot strengthening exercises (see photos).

If you have been battling a lower leg issues or would like to participate in a 2D video running analysis, call or email the running injury and biomechanics experts at Sapphire PT. Our physical therapists will not only return to pain-free running, but also reduce future injury occurrence while improving your running efficiency and performance.  Targeted strengthening and muscle-tendon tissue mobility are the keys to improving running performance at any age.

John Fiore, PT

Sapphire Physical Therapy


  1. Reynolds G, Why Runners Get Slower with Age. New York Times. 2015, Sept 9.

Running U. Running USA 2014 state of the sport – part ii: running industry report http://wwwrunningusaorg/2014-running-industry-report?returnTo=annual-reports. 2014.

2. Goss DL, Gross MT. A review of mechanics and injury trends among various running styles. US Army Med Dep J. 2012; 62–71.

3. McKean KA, Manson NA, Stanish WD. Musculoskeletal injury in the masters runners. Clin J Sport Med. 2006; 16 (2): 149–54.

4. DeVita P, Fellin RE, Seay JF. The relationship between age and running biomechanics. Med & Sci Sports & Exerc. 2016; 48 (1): 98-196.

5. Fukuchi RK, Stefanyshyn DJ, Stirling L, Duarte M, Ferber R. Flexibility, muscle strength and running biomechanical adaptations in older runners. Clin Biomech (Bristol, Avon). 2014; 29 (3): 304–10.


Join Sapphire Physical Therapy on Wednesday, November 15 at 6:30 pm in the Runners Edge basement for an informative presentation. The presentation will focus on how impact loading rates during running relate to injury risk and discuss ways to reduce loading through simple running tips and targeted exercises. Handouts and presentation information will be provided along with refreshments and snacks.

The evening talks will be followed by an interactive demonstration using an accelerometer, which is a tool used to measure and track impact loads as well as foot strike pattern and limb asymmetries during running. The accelerometer is a great addition to Sapphire PT as it collects real-time data while individuals are running in their everyday environment including Missoula’s awesome trails. An outline of the evening’s speakers
and topics include:

– Dr. Willy, Ph.D., PT, a professor at the University of Montana School of Physical Therapy, is an expert in his field and in running injury research will define what impact loading is and discuss how it relates to running injury risk.

– Holly Warner, DPT, physical therapist at Sapphire PT who specializes in running gait analysis and in treating running injuries, will discuss practical ways to reduce impact.

– John Fiore, PT, owner of Sapphire PT and who specializes in running gait analysis and in treating running injuries will provide off-season training ideas to improve strength and running efficiency.

Join us to learn how to incorporate exercise and technology this winter to help you meet your goals and stay on track for 2018.

by John Fiore, PT
Sapphire Physical Therapy

November is a good month to reflect on the past year. As runners, this season reminds us how important it is to be thankful for our experiences and challenges in 2017. In order to set realistic running goals for 2018, it is appropriate to look within for the driving force(s) for why we run.

Understanding the forces behind our motivation to succeed is a complex topic which is relevant to individuals and athletes of all ages and abilities.  Our reasons to set and achieve goals are directly related to our past experiences, childhood upbringing, and the challenges we have faced along the way.  Whether you are a world class athlete or recovering from a recent knee surgery, success depends on your ability to motivate yourself in the face of adversity.  So why do some athletes push themselves to the level of extreme sports?  Is it the success of crossing the finish line, or the struggles endured along the way?  Consider the possible contributing factors below to better understand your unique reasons for pushing yourself to be healthier, stronger, faster, and more fulfilled as a person.

Bridger Ridge Run 2017


Personality Traits:

A March 7, 2016 article by Bradley Stulberg (Outside.com) described biological and personality traits shared by some world class athletes.  Growing up in a goal-oriented household often leads to a goal-oriented adult.  For some, the hard work required to reach an athletic goal fuels the fire to compete. Familiarity with struggle (both physical and/or emotional) at an early age may also motivate a person to challenge themselves through physical pursuits later in life.  The road map of our life steers us over paths which may be a chaotic and rough as the ones we have left behind.  

Biochemical Needs:

The feeling of well-being after achieving a goal is second to none.  Our brain releases neurotransmitters such as Dopamine and Serotonin which provide us with a feeling of contentment and satisfaction associated with physical exercise.  The brain depends on these neurotransmitters for health and balance of moods and our outlook on life.  It is thought that the brains of extreme sport and ultra endurance athletes’ brains require more neurotransmitters to maintain homeostasis. This is often manifested in the frequency and intensity of one’s athletic goals.  Once a goal has been achieved, a more challenging goal is established.  In sports such as mountaineering, climbing, and ultra running, a more challenging goal implies a higher risk of injury or consequence.  Balancing risk and success becomes a grey area for many athletes and must be factored into a healthy, long-term training plan.

Ouray 50 mile, 2017


Social Network:

Missoula is a prime example of a community held together by a love for the outdoors and endless recreational opportunities.  The running, cycling, and skiing communities are vibrant in Missoula, providing a social network of camaraderie and support. Living by example is convenient in Missoula whether you are an aspiring athlete or a world class competitor.

Past Success and Failure:

For many athletes, standing on the podium is not the clearest memory, but rather the vulnerability experienced in failure.  Whether failure was the result of poor training or an injury, the rawness of failure motivates like few other factors.  Fear of failure, therefore, should not impact your ability to set a goal.  Remember, failure can be a stronger predictor of future greatness than present or past success.  Find your own motivational reasons and use them to fuel your passions in life.  Through well planned goal setting, your unique personality needs can be met while allowing yourself to be present for your family, friends, loved ones, and even a stranger or two in need along the way.  


John Fiore, PT
Sapphire Physical Therapy
1705 Bow Street
Missoula, MT 59801