Injuries impact nearly 80% of all runners at some point (Br J Sports Med 2007). While some runners rarely miss a training run or race due to injury, many experience a variety of injuries and/or recurrent injuries. The key to effectively treating and preventing running injuries lies in effectively determining the cause of injury rather than treating the effect or symptoms alone.
The strongest predictors of 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).

Once compensatory movement patterns are addressed through a comprehensive physical therapy evaluation, underlying strength and mobility deficits can be effectively addressed.
If you are looking to improve your running efficiency or are plagued by nagging or recurrent running injuries, a running analysis is a great place to start. Sapphire PT has four physical therapists trained in running analysis. Sapphire PT provides on-site, real-time 2D running gait analysis. We are excited to provide this informative, interactive, diagnostic technology in our Missoula PT clinic. While an iPhone or iPad is capable of recording treadmill running for basic analysis, high-speed camera technology and interpretive software are necessary to objectively quantify joint angles quality of movement. 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. Sapphire PT uses the Simi Aktisys 2D running analysis system. Developed in Germany, the Simi Aktisys software records joint angles along the frontal (anterior and posterior views) 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. Colored LED markers on key body landmarks are read by two high-speed cameras which provide real-time feedback for both the runner and the physical therapist. We also utilize the Run Scribe accelerometer system which accurately measures impact force, pronation angle, pronation velocity. Accelerometer data often reveals compensations for pain, prior injury, or weakness and is used in conjunction with our 2D video system.

Once a compensatory movement pattern is recorded, the runner can return to the treadmill and make changes in his or her running mechanics while observing themselves in real-time on the monitor screen. Coupled with a wireless EMG (electromyography) system, runners can then focus on strengthening weak muscles which play a role in their unique running compensation. 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 recording device. The Sapphire Physical Therapy staff looks forward to helping Missoula runners improve their running efficiency and determining the underlying cause of recurrent injuries.

Running analysis is useful for healthy athletes as well by improving running efficiency. Our website ( has a complete list of our running services. Call Sapphire Physical Therapy (549-5283) to schedule your video running analysis or email me ( for additional information.

John Fiore, PT

Ouray 50 mile

The roads and lower elevation trails around Missoula have melted after being snow-covered since mid-December. April 1st is the day fools like me test out our skiing fitness and ramp up our running mileage in preparation for early season races. April is, therefore, a perfect month to discuss training consistency as a means of achieving distance running success over the next nine months of 2019.

By training consistency, I do not mean following the same weekly training routine all year long. Changing running routes and intensity will improve fitness by challenging the body in different ways. I define training consistency as a training program which regularly includes the necessary components of loading, progressive volume, and adequate recovery.

Loading: Each running stride places 2.5 to 3.0 times our body weight of loading force through our body. How will your body respond to the cumulative loading forces of a 1-mile run versus a 10-mile run? How will your body respond to a Rut-specific fast downhill scramble over rocky terrain after a winter of gliding downhill on skis? How will your body respond to your first Tuesday track speed work session after a winter of slogging with a modified running stride over uneven, icy and snowy surfaces? The answer lies in load training. Think of loading as a strength training workout aimed at increasing your running durability. Building muscle, tendon, and joint health and strength requires loading-specific strength training. I am not referring to body weight resistance exercise, but rather heavy weight, low repetition strength training. Proper loading technique addresses tendon resiliency, muscle strength, and tolerance to both speed and long miles. Without a loading-specific strengthening program, injuries will become part of your running life.

Progressive Volume: Disclaimer: I occasionally do not follow this training rule which is why I am so familiar with the multitude of running injuries I treat in my patients. The take home message is that gradually progressing your training volume will decrease your overuse injury risk significantly. Most runners are familiar with the 10% rule of weekly running volume (mileage) increase. Our long winter combined with a June 30th Missoula Marathon date does not give us much time to safely build training volume. Maintaining consistent fitness over the winter allows one to enter the spring at a higher training volume which helps reduce the urge to “catch up” by doubling your mileage in one week. It is also important to remember that rest days are rest days and rest days are necessary. If you ride your bike 20-miles or swim 2,000 yards on your “rest day” from running, you are further increasing volume to your training week.

Adequate Recovery: Nutrition, hydration, sleep, and body work should be a consistent part of your training routine. The nutritional saying “junk in, junk out” resonates with the miraculous human machine each one of us are. Well rounded whole food nutrition and simple hydration practices will fuel your body for optimum performance. Sleep remains elusive in our modern day society. You are an athlete, however, so 7-9 hours of sleep should be a priority to facilitate recovery and reduce overuse injury risk. Finally, some sort of body work will release tissue tension, muscle tension, improve circulation, and reduce muscle soreness. I intentionally used the general term of “body work” as this may include rolling, massage, myofascial release or manual therapy provided by a physical therapist.

I encourage the reader to seek advice (myself, my fellow PT staff, or one of the other qualified local resources) regarding the specific definition of each training component for you individually. Factors such as running experience, athletic experience, injury history, age, and running-racing goals must be considered on an individual basis. I welcome questions and can be reached by email (

John Fiore, PT

Sapphire Physical Therapy



By: John Fiore, PT
Sapphire Physical Therapy

The sun appeared today and the thermometer reached 40 degrees Fahrenheit (ed. note: this was written last week!). Warmer temperatures and sp ring racing commitments result in a rapid increase in running intensity and distance. Winter legs accustomed to skiing and indoor gym workouts lack the repetitive loading rates which occur while running. Avoid a hamstring injury by avoiding the temptation to rapidly increase your running speed and-or mileage without proper training. A useful concept is Training Load Versus Tissue Capacity. Strength training and progressive tissue loading-specific exercises should be included in regular winter workouts to build hamstring tissue load capacity as we transition from winter sports back to road and trail running miles.

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 and traumatic hamstring muscle pulls can be painful and difficult to treat with rest alone. 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 may result in a season-ending injury. As with most running injuries, gradually increasing training volume and tissue loading is great way to reduce injury risk.

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.

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.

Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are stronger and more prepared to manage the repetitive loading associated with running fast on flats and descending hills at speed (see exercise examples below). Core strength addressing lower abdominal, hip, gluteal, and lumbar stabilizers in a functional manner will reduce the demand on muscles such as the hamstring. Hamstring-specific strengthening with progressive loading will reduce overuse and associated tissue micro-trauma which leads to injury.

In order to quantify hamstring function, a 2D video running analysis may be indicated to determine how you as an individual run. Are you using your gluteus maximus to extend your hip, or is the hamstring acting as the primary mover? Are you over-striding and placing increased tension through the hamstring? A 2D video running analysis is a useful way to detect additional underlying running compensations in the clinic which may influence running biomechanics and resulting hamstring tissue loading.

Finally, do not forget self-care such as adequate recovery, sleep, hamstring release techniques, and eccentric hamstring exercises throughout the year to maximize your tissue load capacity. The exercises listed below are for example only. I recommend seeing a physical therapist to develop an effective hamstring-specific loading exercise program suited to your unique strengths, underlying weaknesses, and running goals. Call or email John and the PT staff at Sapphire PT with any questions or to schedule a consultation (406-549-5283 or

Hamstring Loading Exercises to Increase Tissue Load Capacity:

1. Glut Bridging Progression: Contract your glutes (glute max) together and hold the contraction and lift into a bridge position, holding 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 or single leg bridging without allowing your pelvis to drop. Additional progression includes the addition of a Swiss Ball beneath your heels.

2. Step-downs: Stand on a box or step (begin with a 4-inch box and progress to taller box over time) with a pole for balance assistance as needed. Step down slowly while maintaining alignment through the pelvis, knee, and foot. Increase hamstring loading by landing further forward and by increasing the box or step height. Practice landing quietly “like a cat” to decrease impact loading.

3. Quadruped Plank: Add a single leg lift (hip extension) while maintaining a level back-pelvis. May be modified by resting on your forearms.

4. Eccentric Hamstring Treadmill Stepping: Set treadmill to the slowest speed. Face backward on the treadmill and hold the hand rails. The support side (the left leg shown) is placed off of the treadmill belt. The exercising leg (the right leg shown) is placed on the belt. Slowly resist the forward motion of the belt with one leg as the belt moves. The exercising leg then is moved back to the starting point by flexing the knee and extending the hip.

5. Forward Glider Disc Lunge: Stand with exercising foot on a glider disk (use poles or counter support as needed). Slowly slide foot of exercising leg forward and slowly allow your knee so straighten slightly (do not fully extend your knee or you may do the splits) while avoiding excess hamstring tension. Return to original position and repeat.

6. Nordic Hamstring Curls: Kneel in an upright posture and have a second person hold your lower legs and ankles against the ground (or you may hook your heels beneath a stationary bar). Place hands in front of body and slowly lower towards the floor as shown without excessive hamstring tension. Slowly return to starting tall kneeling position.

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.

3. Finding the balance photo:

By John Fiore, PT
Sapphire Physical Therapy

Icy and snow-packed roads and trails synonymous with winter in Montana are here. While Missoula runners often trade running shoes for ski boots, January marks the beginning of training for the 2019 running season. Runners have numerous ways to transform running shoes into traction beasts to tame the worst winter running conditions. Traction can be added via sheet metal screws, Due North traction devices, or Kahtoola Microspikes. While all of these options will dramatically improve traction, they also place increased stress on the foot. Protecting your feet from the focal pressure points secondary to running shoe traction devices will increase winter running enjoyment and reduce foot injury.

Ice is as firm as concrete. Add wire and metal traction devices between and icy surface and the foot and the stage is set for metatarsalgia. The term metatarsalgia is used to describe “pain in the metatarsal bone(s) of the foot. The metatarsals are located in the forefoot between the bones of the midfoot and toes. Metatarsals are long, slender bones which function to absorb impact and allow the foot to accommodate to uneven surfaces. When a metatarsal becomes irritated due to high, repetitive impact, a bone inflammatory response occurs. Reducing impact, pressure, and weight bearing will reduce metatarsalgia symptoms. A simple rock plate can be made at home to reduce the risk of developing metatarsalgia secondary to running with winter traction devices. Below are several photos and a description of how to make any pair of running shoes into a pair of metatarsalgia-proof winter running beasts.


  • Flexible cutting board (purchased for $4.99 at Ace Hardware)
  • Sharpie pen
  • Scissors
  • Running shoes
  • Traction device (Kahtoola Microspikes used for example)


Step One:

  • Remove running shoe insoles and place on flexible cutting board
  • Trace insole on flexible cutting board using Sharpie pen
  • Cut out new rock plate with scissors



Step Two:

  • Trim rock plate as needed to fit inside running shoes
  • Insert rock plate in running shoes
  • Place insoles back in running shoes on top of rock plate


Step Three:

  • Put running shoes on and attach Kahtoola Microspikes
  • Enjoy winter running without associated metatarsalgia pain