How did we get here?

I have recently been inspired to get my blog on. When I started the Doctor G blog, it was a means to consolidate my thoughts after talks to a local team or group. I found it easier to have my key points listed on the blog before the talk so I could refer people to a central place after the talk. More recently, I find the inspiration for my posts to be for the purpose of shaping something bigger such as a book. As I stew over this great idea, I have taken pause to reflect on why physical therapy and running are such a great match. Research has taught us that injuries are very prevalent amongst runners. We have also learned along the way that many physical therapy interventions such as strength training, and movement pattern retraining can change a runner in a very short period of time. Often, PT interventions will help a runner continue to run with diminished or no pain. Keeping a runner running keeps all involved happy.

Overall, I think one of the most important concepts we have learned in sports medicine research is that most runners are vulnerable to injury because of training errors, and also relative instability. Let's review both:

Training errors- This is a simple one. Think too much, too fast. The tissues involved are overwhelmed by the cumulative stress of these increases. A question I always ask runners is what's different? I want to know if they have changed their training distances, surfaces, intensities, frequencies, or shoes. Usually something has changed. Usually something has increased such as one or more of the above components. It is also likely that something has decreased such as recovery, or consistency with stretching or strengthening. These changes cause the involved tissues to be overloaded. Tissue breakdown leads to pain which leads people to the clinic.

Relative instability- This is my favorite point to runners. Most runners are used to running straight ahead. The muscles that lead them in this direction are very well developed. They are very smart in that they know how to work to bring the body forward very well because that pattern of movement has been repeated over and over again. A runner can put thousands of reps on their legs during a race or training run so the concept of muscle memory is very real. However, this repetition is what really dupes most runner into thinking that running is all they need to do. From a stability perspective, the muscles that help a runner remain stable, and "in alignment", are oriented in planes of motion not isolated in running. Think of it this way: If you run North/ South but the stabilizing muscles go East/ West, why would a runner expect to be free of injury? This point highlights why runners need to add to their training some component of strength drills for the hips and core. The hips, specifically the glutes and hip rotators, are the cornerstone of controlling leg movements in standing. Consider them the foundation of the leg, to a degree. I make that qualifier because really the foundation needs to be designated as the glutes, which is part of the larger group of muscles called the core. Strength and stability in these areas position a runner to avoid most common running injuries. Strength and stability in these areas come from doing strengthening exercises moving in planes other than just straight ahead. Consider side stepping with a resistance band, rotating the hips against a resistance band, and adding to that balance work. Balance work is a great equalizer as it teaches a runner to control the strength they are developing. Remember, our goal is strong and smart.

Midstance stability

One concept we emphasize with runners in the clinic at Sports and Spinal physical therapy is midstance stability. Research tells is that the middle point of a runner's stride is the point at which the ground reaction force up the leg is greatest. This point in the stride is appropriately termed "midstance". Think of it as after "initial contact", which is when a runner's foot first contacts the ground. Midstance comes when the foot is completely flat, and the opposite leg is swinging forward past the stance leg( see below). It is literally the middle point of the stride. Given the forces up the leg are largest at this time, we need to ensure that the runner's leg remain stable to the ground reaction forces. Even the slightest deviations, such as the kneecap turning inward, can dramatically increase strain to the involved tissues. The end result of this overload of stress could be one of the many mechanical problems runner's have such as ITB syndrome, or patellofemoral pain syndrome.

If I had just a few minutes to examine an injured runner, I would undoubtedly check their midstance stability. How would I do that you ask? Simple, just take the runner through a series of tests that evaluate how stable they are in midstance. A few of my favorite tests include:

1) Single leg balance: Ask a runner to stand on one leg while maintaining a balanced position. Typically, once a runner is set in a balanced position, I ask them to close their eyes.
I would like to see a runner maintain a balanced position for 30 seconds. My idea of a balanced position is where all components of the kinetic chain ( think from the foot up to the lower back) are stable, i.e. not teeter tottering. I will look at the foot/ankle to see if it remains in contact with the ground, or if the toes come off the ground. I will look at the knee to see that it maintains it position. A common deviation is the kneecap is turning inward and outward as the runner tries to maintain balance. I would look at the thigh bone to see if it is following the knee inward. The reason balance is so important is because it indicates a solid connection between the joints of the leg and the brain. We want the body to rely on the balance feedback it receives from the joints of the leg, versus just taking input from the vision and inner ear. The reason behind this desire is that is establishes a very quick feedback mechanism for the runner.

2) Single leg swing- This test takes the balance test above and makes it functional. I will ask a runner to stand on one leg and swing the opposite leg forward and back as if they were going through a running type motion. The test shows me how stable the runner is in a more dynamic fashion, one that mimics running. I will watch the leg the runner is standing on to look for instabilities. I will also watch the leg that is swinging to get a gross sense of range of motion of the hip. I will also look at how the swinging leg influences the lower back. I hip that is overly tight often results in a more stressful moment being imparted on the lower back. This is an important point we see time and time again in physical therapy : a stiff joint will typically adversely influence joints above and below.

3) Single leg squat- This is another functional test for runners. I ask the runner to stand on one leg. Once balanced, I ask the runner to squat to 45 degrees times 10 repetitions. Guess what I look for? You guessed it! I look for what is happen with the kinetic chain. Mainly what I look for is whether the chain stays stacked on top of itself. Notice the difference between the two images below. Obviously the B image is less stacked as the knee drifts toward midline, and the thigh rotates inward. Note how the torso is influenced also. I find that instabilities in the leg can influence any part of the leg, but can extend all the way up to the spine too.



4) Step down test-This test is similar to the single leg squat. I ask the runner to stand on top of a step. The test has a runner lowering one foot toward the floor. The foot comes slowly down to the floor without actually stepping off the step. I ask runners to do 10 reps on one side before they switch. I look at the chain just like I do in the squat test above. I often notice a runner doing fine with the squat test, only to flail on the step-down. Consider that the leg is being asked to do something different that just squat. The ankle is going through a greater range of motion which can be a limiting factor. The same applies to the knee.

Collectively, the above tests give me much useful information. They tell me how strong a runner is, how well they control their movements, where they are limited in flexibility, and ultimately what their MIDSTANCE stability is. This information can help me to understand why they are injured, and how I am going to help them recover.
I often cue runners to hold their foot in a "neutral " position such that the runner is actively maintaining the arch in their foot in a mid line position.

Running form

It seems the buzz of barefoot running has been replaced by the minimalist movement. With this change has come an ongoing discussion on running form and how to ensure efficiency/prevent injury. Though I agree that running form is a subject worthy of discussion, it should be noted that distinct research showing that injury rates diminish based on proper running form is not quite there. We have seen good results with changing form to diminish loading rates which will make a runner less vulnerable to common injuries. However, as is often the case, we need to allow the research to catch up to the buzz.

I recently gave a talk about running form which I would like to review. My goal was to keep things simple which seems to always work best, especially when changing an ingrained habit like running.

Run Softly: As crazy as it sounds, listen to what you sound like when you are running. Do you hit harder on one side versus the other. If you do, chances are that is the side which will be more vulnerable to injury. Do you land so hard that you would be considered a "godzilla" runner!?!
All joking aside, studies show that if you focus on landing softly, you can diminish ground reaction forces considerable. That, my friends, is a good thing. When I give the cues to "run softly" most folks look at me like I am nuts. No sooner do they give me the stink eye do they concentrate and really make a change. You can hear them get soft. It might be only for a few strides, but they do it. Give it a try! What is happening when you do this is likely the foot is moving back closer to the center of mass such that the foot is not slamming into the ground so hard. Moving the foot closer also causes cadence to increase, and stride length to decrease. Both of these are good for decreasing stress up the legs. The initial contact point will also change when you get "soft". Usually as the foot comes back closer to COM, the initial contact point is more on the mid foot or forefoot.

Run Tall-Another topic discussed in the running form mix was the value of good upright posture. If a runner is overusing his/her lower back muscles, the curve in the lower back tends to increase. As a result of the abnormal position, the spine is under more stress/strain. Also, running with an increased lower back curve moves the center of mass posteriorly. This scenario causes the foot to be brought anterior to the COM. This is known as "overstriding"( see photo). Think about actively having an upright posture with a gentle bracing of the core muscles. Add to this 'tall' posture as slight forward lean from the ankles(see photo of runner outside below), and you are ready for action. If you are tall with a slight lean forward, the foot automatically stays underneath you.
Another point about posture is to remember that you can't sit slouched at your desk all day, and then expect the body to come to perfect erect postures. Another incentive to double check your desk set-up to ensure that it is facilitating upright posture. it does not hurt to get up and move around a bit multiple times per day for a change.









Cadence- Another discussion point from the run clinic was consider a runner's cadence, or their RPM. A gold standard is 90 strikes per minute on one side. Most runners I see in the clinic are moving much more slowly than this. It is important to not try to dramatically change your cadence. If you count your contacts on one side and you get 160 when you double it, try to increase by 5-10%. Research shows that increasing cadence by as little as 5% will diminish the impact stress up the leg, which is what we want. You can use music that has 180 beats per minute to help, or a metronome app for your iPhone. Think about increasing your turn over if you need to. This change typically causes stride lengths to decrease, runners to land less often on their heels etc.

KISS- Notice a trend here? If you change one component of running form, it invariably changes another. I see in the clinic that one client will respond well to one verbal cue, and the next client flounders with the same cue. With each run, consider focusing on one thing, and don't try to maintain that focus for the whole run. If you are focused on being "soft", do so for a minute, and then run normally. Come back to that cue every 10-15 minutes such that you get in a few rounds of practice. Next time, practice the next one!

Overall, my perspective on running form is biased by what I see in the clinic and what I read in the research. In the clinic, I see injured runners. These injuries tend to be around the knees, pain under knee cap or IT band. Both of these injuries will be strained by overstriding so I commonly ask runners to be aware of keeping their initial contact point closer to their center of mass. I can achieve the same goal with increasing their stride contact. These changes seem goofy but the research supports that real changes can be made in running form just by being more aware of how you are running. have fun out there!

Hometown rocket

After nearly a year of being dormant, it is high time to kick start the DGST blog. What better way to get rolling than to speak of Matthew Centrowitz Jr, and the ever growing CentroNation. If you were under a rock during the recent track and field world championships, you missed some spectacular racing by the US team. Of note was a bronze medal by Matthew in the men's 1500m. He performance was inspiring for many, and seemed to be a shock to the racing community given Jr is only 21 years old. However, given Centro won the NCAA title this spring, and outkicked Lagat to win Nationals, the kid has some serious chops. He raced a smart race, and really hung it out there. What I love is that he hung in there over the last 300m. He held steady and reeled in enough competitors to place himself on the podium. Digging deep! Gotta love that. So, kudos to Matthew Jr. for making us all proud. Well done!