I perform running analyses everyday in order to improve performance or get an athlete past an injury. Viewing the changes in muscle activity and joint angles of each phase from stance to float to swing phases provides insight into a runner’s performance and problems. The incredible coordination of running is not conscious and lets me get a glimpse of a person’s overall nervous and musculoskeletal system. It is a natural process (at least prior to coaching).

But if it is natural, what about it hurts us?  Can we analyze your gait in enough depth to figure out why you are hurting?

The truth is that analyzing running gait is not enough.  The how and why someone runs with their current pattern or why they may be susceptible to an injury cannot be determined by watching them run without checking out other ‘things’. Injury prevention is not as simple as a switch to a midfoot or forefoot (which anecdotally is the most common statement I hear from repeat injury offenders).  AND injury prevention is never a clear proposition- it is more of moving probability that you are constantly trying to lower through screening and intervention.

What are these other ‘things’?

We have to dig into the exam, which seems to surprise runners that come to see us because we have a reputation as gait specialists.  There have been runners who come in for a running analysis who I do not analyze for running gait because of the glaring problems in the basic exam that must be addressed before we move on to a gait correction.  Without a thorough exam, running gait cannot be explained.  Sure, I can determine how much pelvic drop is present, but the ‘why’ is missing.  And the ‘why’ is critical for injury prevention and overall performance.

Today’s post will give an overview of how to use running analysis within a framework of diagnosis.

At our clinic we dig into 5 general areas:

1. Pain – when pain is present, movement changes.  Think of how a person in pain starts to hobble at the end of the race.  While they may be still running and pushing through, the pain will typically not allow their normal pattern to come through. If you have pain when you walk through the door, our number one goal is to understand what the pain generator is.

2. Deformity/Flexibility Limitations/Passive Range of Motion Loss – humans are amazing at compensation. A limit in muscle length or at a joint will lead to a change in pattern.  For example, we may see the foot turned out if the big toe is stiff.

3. Strength Deficit – this is probably the most common problem.  For example, the loss of posterior tibialis strength can lead to rapid pronation that leads to injury and medial ankle overload. It is the rapid speed of deceleration that relies on passive structures, instead of doing too much pronation, that is the problem.

4. Motor Control Impairment – poor single leg balance or sequencing of movement are common problems. We can check this with a step-down test.  I also throw in muscle inhibition in this category.  We commonly see runners that test very strong but after running for 5 minutes, they test very weakly.  This is not fatigue but altered neuromuscular control.

5. Sensory Impairment – this is the least common problem at our clinic and has been related to neuropathy caused by different pathologies. A basic example is a lack of feedback from the foot leading to changes in strike and stance phases-like a foot slap or toe drag leading to falls.  As I have written before, runners seem to become visually dominant. We require our runners to balance with their eyes closed.  The results can be funny and scary as many cannot do it!

Picture

Figure 1. Possible Factors Influencing Running Mechanics. Modified from MD, J. P. & PT, J. B. P. Gait Analysis: Normal and Pathological Function. (Slack Incorporated, 2010).

From these top five factors that can influence running mechanics, we also look at the individual’s history. For example, a recurring hamstring injury with training above 50 miles indicates a problem even if the runner states it’s not currently present. Deeper investigation of each individual muscle using dynamometry may be needed, not just manual muscle testing.

From these top five factors that can influence running mechanics, we also look at the individual’s history. For example, a recurring hamstring injury with training above 50 miles indicates a problem even if the runner states it’s not currently present. Deeper investigation of each individual muscle using dynamometry may be needed, not just manual muscle testing.

Case Study

Here is an example of a case that we were able to handle with two gait training sessions

Subjective

Who: Avid female runner and swimmer increasing running mileage and speed over the past several months.

What: Sharp pain in the right low back and buttock area with running, especially longer distance.  Following the long run, the pain will change into an aching pain for the rest of the day.

When: Pain onset was rapid.  It started after a single run and then progressively worsened for each subsequent run.  At time of the exam, she was not able to run without pain.

Where: right sided low back and buttock pain.  Occurs while running on concrete and asphault.

Why: Increasing mileage.  No change in shoes.  Performing light stretching prior to running.  Changing shoes did not impact her pain.

Exam

Pain with provocation testing of the sacroiliac joint.  Pain reduced with SI loc belt.
Pain with forward flexion and left sidebending. Positive straight leg raise.  Pain with
Strength testing found no deficits.
No deformity present.
Normal sensory testing.
Motor control: unable to produce normal step down test (meaning excessive knee valgus and pelvic drop. Pain in low back and buttock recreated.  Pain completely resolved with addition of SERF strap.

Running Analysis

Looking at the video (not the real video of the client however the gait pattern is similar), it is clear that she is not controlling the pelvis during midstance. This highlights how critical it is for you to test strength and motor control because her gait makes you think she is missing strength in the hip muscles but she does NOT. So to correct the problem we needed to rework her motor plan which can be much, much faster.

Treatment

Due the sacroiliac involvement, we had her wear a SI loc belt for 1 month for 23 hours per day.

At the initial evaluation, we focused on running cues that produced the gait pattern that was pain free. The cuing that worked was “lean to the right.”

She was given a SERF strap to wear for all runs that she did not want to work on her gait.  For all other runs, she was required to run while focusing on “lean to the right”.

At the second follow up, she was now able to run pain free for 10 minutes.  We eliminated the cue lean to the right, and used “keep your knee apart” which normalized her knee (stopped knee valgus).  We decided on a running program over the next 5 weeks with strategies to use anytime pain occurred that she would use.  Therefore, PAIN BECAME FEEDBACK FOR CHANGE.  Pain became a tool for progress instead of something to fear.

At her third follow up, she was now 6 weeks from her initial evaluation.  She had eliminated the SERF strap at week 3.  She was at her desired running volume.  We retested her for the pain provocation tests and she was negative.  We eliminated the SI loc belt and she was good to run as much as she wanted.  The step down test was given as an exercise to continue progressing her single leg control.  She was able to perform with no deviation or pain.

What is different about SPC and how we use running analysis?

If you have been to physical therapy previously, you may be surprised at the approach.  First, it is a horrible idea to take away a healthy activity like running if someone is motivated to do it.  So we make an all out effort to keep you running from day one! There are numerous ways to do this from running uphill to eliminate load, to taping, to bracing. Second, we do not give a million exercises. We focus on one or two that you know inside and out.  We call these keystones to health.  This becomes part of your routine that is not hard to insert in a normal exercise program.  We also do not make large changes to gait unless absolutely necessary.  The thought that you must switch your foot strike is not the correct change in most cases.

References

Schwellnus, M. P. Cause of Exercise Associated Muscle Cramps (EAMC) — altered neuromuscular control, dehydration or electrolyte depletion? British Journal of Sports Medicine 43, 401–408 (2009).

Wagner, T. Strengthening and Neuromuscular Reeducation of the Gluteus Maximus in a Triathlete With Exercise-Associated Cramping of the Hamstrings. Journal of Orthopaedic and Sports Physical Therapy (2009).

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