Biomechanical Assessment

and Treatment of Running Injuries

Created by Francine EastwoodCreated by Francine EastwoodBScPT, ART Provider ®, Founder of PSI Runner’s Clinic, Senior Clinical Leader

PSI Sports Medicine Centre, 1000 Palladium Dr., Kanata, ON.

www.psiottawa.com

Picture of elite African distance runners

What we will cover:What we will cover:The Running paradoxThe Running paradox

Treadmill vs. Over ground Treadmill vs. Over ground runningrunning

Efficient Running Form – the basicsEfficient Running Form – the basics

PSI’s Runner’s ClinicPSI’s Runner’s Clinic– How to assess a runnerHow to assess a runner– The good, the bad and the just plain uglyThe good, the bad and the just plain ugly

What causes Injuries?What causes Injuries?

Treatment of Common Running Treatment of Common Running InjuriesInjuries

The Running ParadoxThe Running Paradox

Natural Natural == efficient or biomechanically efficient or biomechanically soundsound (Miller, 2002)(Miller, 2002)

Ones natural running style is a motor habit Ones natural running style is a motor habit influenced by: innate athleticism, training, influenced by: innate athleticism, training, compensations for injuries, responses to compensations for injuries, responses to aging process aging process (Miller, 2002)(Miller, 2002)

Do runners practice running?Do runners practice running?

Most runners work on increasing speed and Most runners work on increasing speed and mileage, very few work on form.mileage, very few work on form.

RunningRunningSpeed determined by:Speed determined by:

Cadence - number of steps/ minute Cadence - number of steps/ minute constant from 5-10mphconstant from 5-10mph

Stride length – distance between IC of same foot Stride length – distance between IC of same foot Varies: increases with speedVaries: increases with speed

Running or “jogging”:Running or “jogging”:– Novice or Intermediate: 5 -10mphNovice or Intermediate: 5 -10mph

Cadence: 168-180 steps/min Cadence: 168-180 steps/min (Kaneko et al., 1987)(Kaneko et al., 1987)

– Elite distance runners: 10 - 13 mph Elite distance runners: 10 - 13 mph Cadence: 180-184 steps/min Cadence: 180-184 steps/min (Miller, 2002)(Miller, 2002)

Treadmill vs. Over ground Treadmill vs. Over ground runningrunning

Treadmill: Treadmill: step lengthstep length contact timecontact time vertical vertical

displacementdisplacement

Treadmill:Treadmill:

Cadence Cadence (steps/min)(steps/min)

Forward leanForward leanOther:Other:

• EMG generally similar with EMG generally similar with minor differences minor differences (increased (increased work of HS,work of HS,decreased work of RF)decreased work of RF)

A number of researchers have concluded that the A number of researchers have concluded that the TM is an acceptable tool for studying running TM is an acceptable tool for studying running (Schache A.G. et al. 2002)(Schache A.G. et al. 2002)

Wank V. et al., Wank V. et al., 19981998

Running Economy and Running Economy and Efficient Running FormEfficient Running Form

Running Economy: energy demand for a Running Economy: energy demand for a given velocity of sub maximal runninggiven velocity of sub maximal running

The best athletes are usually the most economical.The best athletes are usually the most economical. (Noakes, 1988)(Noakes, 1988)

Efficient running based on elite modelEfficient running based on elite model

Biomechanical factors influencing Biomechanical factors influencing Running EconomyRunning Economy

Efficient running requires: momentum in Efficient running requires: momentum in

sagittal plane with minimal VD, FP, TP motion.sagittal plane with minimal VD, FP, TP motion. (Geraci, Michael C., Brown, Walter. 2005)(Geraci, Michael C., Brown, Walter. 2005)

Improved Economy IF Improved Economy IF DECREASEDDECREASED::• vertical oscillation (Cavanagh, Pollock & Landa, 1997)

•support time (Paavolainen et al., 1999)

•peak GRF (Anderson, 1996)

Improved Economy Improved Economy if INCREASED:if INCREASED:Cadence (180 +/- Cadence (180 +/- 10)10)Knee flexion during Knee flexion during supportsupportforward lean of trunk forward lean of trunk (Williams & Cavanagh, 1987)(Williams & Cavanagh, 1987)

PSI’s Runner’s ClinicPSI’s Runner’s ClinicThe GoalThe Goal

• Educate runners on “good” running form. Educate runners on “good” running form. • Educate runners on training progression and injury prevention.Educate runners on training progression and injury prevention.• Specifically for runners with chronic injuries, or those who are Specifically for runners with chronic injuries, or those who are

looking to make changes to their biomechanics.looking to make changes to their biomechanics.

The Process:The Process:• 60 minutes 60 minutes • Review of training, past injuries and rehabilitationReview of training, past injuries and rehabilitation• Shoe assessmentShoe assessment• Functional, strength, flexibility assessmentFunctional, strength, flexibility assessment• Video assessmentVideo assessment

4 min. warm-up4 min. warm-up1% incline, speed (varies from jog to 1% incline, speed (varies from jog to

speed)speed)Digital video camera from R/L/B/ on TM and Digital video camera from R/L/B/ on TM and

OutsideOutside

Video Analysis:Video Analysis: : ~ 60 min. for analysis and exercise program : ~ 60 min. for analysis and exercise program using Dartfish softwareusing Dartfish software

Follow Up visits: Follow Up visits: ~ 60 min. for education and exercise program~ 60 min. for education and exercise program

Running Form- check listRunning Form- check list

Observation:Observation:Cadence (180 +/- 10) Cadence (180 +/- 10) Sound (GRF), Smooth & SymmetricSound (GRF), Smooth & SymmetricPosture (head, shoulders, trunk, core)Posture (head, shoulders, trunk, core)Arms:Arms: compact; elbow or hand does not cross midline compact; elbow or hand does not cross midline Foot contact/placement:Foot contact/placement:– as close to vertical line (plumb line) going through your hipsas close to vertical line (plumb line) going through your hips

Video Analysis:Video Analysis:Short contact timeShort contact time: 0.200-0.300 sec.: 0.200-0.300 sec. (Buckalew et al., 1986)(Buckalew et al., 1986)

Angles at pelvis Angles at pelvis (4-5 deg.)(4-5 deg.), hip/knee , hip/knee (20/25 deg.)(20/25 deg.), ankle , ankle (8-10 (8-10 deg. pron.)deg. pron.)

Lean forward with entire bodyLean forward with entire body (chi running, pose tech)(chi running, pose tech)Vertical Displacement Vertical Displacement (minimal < 8cm)(minimal < 8cm)

Running gait cycleRunning gait cycleSwing phaseSwing phase

M. Swing: M. Swing: Knee flex speed Knee flex speed dependant dependant

T. Swing:T. Swing: Ecc. HS and Ecc. HS and Popliteus. Popliteus. See “paw backSee “paw back” just ” just prior to ICprior to IC

12 mph 6.5mph

Running gait cycleRunning gait cycleSupport PhaseSupport Phase

Max hip adductor activity just prior to IC Pronation occurs in first 50% of stance phase

Running Gait Cycle - Upper body Running Gait Cycle - Upper body MechanicsMechanics

Arms can help Arms can help max. running max. running efficiencyefficiency– Compact, front to Compact, front to

back arm swingback arm swing– Drive back, recover Drive back, recover

forward (40-60 forward (40-60 hum. ext)hum. ext)

– Do not cross Do not cross coordinate systems coordinate systems

(SP) (FP)(SP) (FP)

Running FormRunning Formthe good, the bad and the the good, the bad and the

uglyugly

Runner #1 – The elite model style

Runner #2 – The jogger style

Runner #3 – The peculiar style

Running Injuries StatisticsRunning Injuries Statistics

16.4 million people run in US (>100 d/year).16.4 million people run in US (>100 d/year). Marathons are growing in popularity.Marathons are growing in popularity. There are to date over 530 marathons/year.There are to date over 530 marathons/year. Up to 80% of runners are injured every year.Up to 80% of runners are injured every year. More than 40% of injuries occur at the knee. More than 40% of injuries occur at the knee.

HOWEVER…..HOWEVER….. Running decreases death by 63%!Running decreases death by 63%!

Top 5 Running Injuries Top 5 Running Injuries (overuse)(overuse)

1.1. PFPSPFPS

2.2. ITBSITBS

3.3. Plantar FasciapathyPlantar Fasciapathy

4.4. Achilles TendonopathyAchilles Tendonopathy

5.5. MTSS (shin splints)MTSS (shin splints)

Running InjuriesRunning Injuries

How Do Injuries Happen? How Do Injuries Happen?

Extrinsic Factors (shoes, orthotics, surface)Extrinsic Factors (shoes, orthotics, surface)

Intrinsic Factors (biomechanics, msk Intrinsic Factors (biomechanics, msk dysfunction)dysfunction)

Stress on Tissue (duration, type, intensity)Stress on Tissue (duration, type, intensity)

Running InjuriesRunning Injuries

80%

Why do they do too much, Why do they do too much, too soon?too soon?

And some just don’t do enough!And some just don’t do enough!

www.therunningclinic.ca

Injuries and Biomechanical FlawsInjuries and Biomechanical Flawsmy observations….my observations….

InjurInjuryy

Potential Stride Potential Stride FlawFlaw

Correct Correct formform

PFPSPFPS

ITBSITBS

IR Femur during IR Femur during contact and support contact and support phasephase

Pelvic drop (opposite)Pelvic drop (opposite)

““keep knees apart”keep knees apart” cadence/MFS cadence/MFS

strength glute med/strength glute med/

tone adductors tone adductors

ADD Femur during ADD Femur during contact/ feet cross over contact/ feet cross over midline/ whip midline/ whip

““Run with line Run with line between feet”between feet”

““Drive from hip not Drive from hip not foot” – as if running foot” – as if running through tall grassthrough tall grass

““good arm carriage”good arm carriage”

Injuries and Biomechanical FlawsInjuries and Biomechanical FlawsInjuryInjury Potential Stride FlawPotential Stride Flaw Correct Correct

form/strength form/strength vs. lengthvs. length

Plantar Plantar FasciitiFasciitis/s/ATAT

Amount/duration of Amount/duration of pronation, lacking dflx pronation, lacking dflx ( foot ER)( foot ER)

““push with big toe” push with big toe”

cadence, heel strikecadence, heel strike

+/- dflx ROM, ecc calf+/- dflx ROM, ecc calf

Shin Shin SplintsSplints

Stress Stress ##

As above + Loud/slaps As above + Loud/slaps (fatigue)(fatigue)

Heavy heel strike, lands Heavy heel strike, lands far in front plumb line far in front plumb line (inc GRF)(inc GRF)

““Soft strike”Soft strike”

MF strike, land with MF strike, land with foot underneath bodyfoot underneath body

LEAN + cadenceLEAN + cadence

Minimalist shoes if Minimalist shoes if anterioranterior

HS HS strainstrain

Overstride, land with Overstride, land with foot far in front, pull foot far in front, pull type gait, slow cadence, type gait, slow cadence, overleans, stiff L/Soverleans, stiff L/S

Upright + cadenceUpright + cadence

Avoid trunk rotationAvoid trunk rotation

MF strike, look at L/SMF strike, look at L/S

Treatment of Treatment of Running Running InjuriesInjuries

PROTECTION – ACUTE AND SUBACUTE STAGES

Taping, brace, orthoticsIceRestTherapy – ART, MT, US, IFC, APOther: injections (cortisone, PRP), shock wave….

ADAPTATION –CHRONIC (THE MISSING LINK)Eccentric exercisesRe-load tissues gradually in sport specific mode

return to run programplyometrics

www.therunningclinic.ca

Return to Run Level 1

The Shoe DilemmaThe Shoe DilemmaMYTH: Cushioning prevents injury by reducing shock to the runner’s body.

FACTS: 1990’s: Technological advances in running shoes without scientific evidence.

2000’s: Clinical and scientific results do not support the fact that shoe cushioning reduces the incidence of running injuries.

Cushioning does not change the stress on the skeleton, nor decrease the GRF.

The running shoe is one of the primary causes of altered running biomechanics.

The shoe reduces the body’s natural absorption reflexes.

The Shoe DilemmaThe Shoe Dilemma

FACTS:Fewer injuries are reported with running shoes that have thinner soles or that are less expensive.

Barefoot runners report fewer injuries than those with running shoes, even in countries where both populations coexist.

Barefoot running produces less pronation and supination and the same or LESS ground reaction forces (GRF) than shod running

(2010-Lieberman, 2009-Squadrone, 2009-Vormittag, 2008-Donoghue, 2007-Clinghan, 2006-Shakoor)

Barefoot vs. ShodBarefoot vs. Shod

The Running ShoeThe Running Shoewhat to wear?what to wear?

All changes should be done gradually (4 + weeks)

Pick a shoe that is simple, flat, flexible (light trainer / racer)

Pick a shoe that is comfortable and has proper fit

CAUTION: MFS and running with minimalist shoes will increase work of gastroc- soleus complexe, AT, plantar fascia, IFM and metatarsal heads.

In Summary:Natural is not = Efficient running formBiomechanical Assessment (observation +/- video analysis) is an important part of assessing/treating a runnerEfficient running form always has a high cadence (180) 80% of all running injuries are caused by overloadRunning decreases death by 63%!

Top 10 Ways Top 10 Ways To Injure Yourself While RunningTo Injure Yourself While Running

Wear shoes that are trendy and that are uncomfortable. Never do any core strengthening. Start every run without a warm up, and go hard right

away. Skip the easy or off days and run more than you are

ready for. Run really far and hard, often. Take weeks off, then start back up where you left off. Don’t listen to your body. Pain and stiffness are not good

warning signs. Change your running form dramatically without giving

yourself time for any sort of muscle adaptation. Do not listen to your coach or therapist and wait until

your injury is chronic before seeking help. If you are new to running (< 3 yrs), start with a

marathon. Don’t bother giving yourself time to work up to what the best athletes in the world take years to do.

As seen in Irun magazine, R. Hellard/F. Eastwood, 2011

Recommended ReadingRecommended Reading

BOOKS:BOOKS:Lore of Running, Tim Noakes, MD. Fourth Edition, 2003Lore of Running, Tim Noakes, MD. Fourth Edition, 2003Programmed to run, Thomas S. Miller, PhD, 2002Programmed to run, Thomas S. Miller, PhD, 2002Websites: www.posetech.com and www.chirunning.com Websites: www.posetech.com and www.chirunning.com andandwww.therunningclinic.ca www.therunningclinic.ca

ARTICLES:ARTICLES: See website: www.therunningclinic.ca - go to experts around See website: www.therunningclinic.ca - go to experts around

the worldthe world

SPECIAL THANKS TO:SPECIAL THANKS TO: Blaise Dubois – Physiotherapist and founder of the running Blaise Dubois – Physiotherapist and founder of the running

clinic websiteclinic website Eric Nielson – Chiropractor at PSI Sports Medicine WestEric Nielson – Chiropractor at PSI Sports Medicine West Eric Collard – Chi Running Instructor: Eric Collard – Chi Running Instructor:

www.ecinc.ca/chirunning.html www.ecinc.ca/chirunning.html

Study:Study: Factors related to top Factors related to top running speed and economyrunning speed and economy

(Int J Sports Med. 2007 Aug, Nummela A, Keranen T, Mikkelsson LO)(Int J Sports Med. 2007 Aug, Nummela A, Keranen T, Mikkelsson LO)

Goal: investigate the relationships between running mechanics, top Goal: investigate the relationships between running mechanics, top running speed and economy in young endurance athletesrunning speed and economy in young endurance athletes

Method: 25 endurance athletes (19.8 +/- yrs)Method: 25 endurance athletes (19.8 +/- yrs)– TEST 1: 8 x 30m with increasing speeds (measured ground TEST 1: 8 x 30m with increasing speeds (measured ground

reaction forces and stride characteristics)reaction forces and stride characteristics)– TEST 2: incremental 5-6 x 1000m (measured running economy at TEST 2: incremental 5-6 x 1000m (measured running economy at

the speed of 3.89m/s and Max O2 uptake) the speed of 3.89m/s and Max O2 uptake) *(~4.29min/km) or (6.86min/mile) or (8.4miles/hour)*(~4.29min/km) or (6.86min/mile) or (8.4miles/hour)

Results:Results:– Ground Contact time was the only factor which correlated Ground Contact time was the only factor which correlated

significantly with both running economy and max running speedsignificantly with both running economy and max running speed

Conclusion: Therefore, short contact times required in economical and Conclusion: Therefore, short contact times required in economical and high speed running suggests that fast force production is important for high speed running suggests that fast force production is important for both economical running and high top running speed in distance both economical running and high top running speed in distance runners.runners.

Purpose/goal: To document actual foot strike patterns during an elite half marathon

Method:283 runners filmed at the 15km mark obtaining sagittal foot landing/take off

Results:Rear foot strike (RFS) = 74.9% of runners (top 50 runners = 62%)Mid foot Strike (MFS) = 23.7% of runners (top 50 runners = 36%)Forefoot Strike (FFS) = 1.4% of runners (top 50 runners = 2%)

Conclusion:•Contact time increased with slower runners especially with RFS. •Percentage of MFS as running speed

•Therefore…. A shorter contact time might contribute to higher Running Economy

Study: Foot strike patterns of Study: Foot strike patterns of runners at the 15-Km point during an runners at the 15-Km point during an

elite-level half marathonelite-level half marathon

Hasegawa H, Yamauchi T, Kraemer WJ. 2007Hasegawa H, Yamauchi T, Kraemer WJ. 2007

Several developed programs Several developed programs for for

‘ideal running form’‘ideal running form’

Pose TechniquePose Technique (www.posetech.com )(www.posetech.com )

Founder: Dr. Nicholas S. Romanov, PhD, 2 time Founder: Dr. Nicholas S. Romanov, PhD, 2 time Olympic coachOlympic coach

Established in 1977Established in 1977

2 peer reviewed scientific studies 2 peer reviewed scientific studies

Chi RunningChi Running (www.chirunning.com )(www.chirunning.com )

Founders: Danny Dryer Founders: Danny Dryer

Developed in 2003 – from Chi LivingDeveloped in 2003 – from Chi Living

No peer-reviewed scientific literature foundNo peer-reviewed scientific literature found

Reduced Eccentric Loading of the Reduced Eccentric Loading of the Knee Knee

with the Pose Running Methodwith the Pose Running Method

Arendse, Regan E; Noakes, Timothy D.; Azevedo, Liane B.; Romanov, Nicholas; et al. Arendse, Regan E; Noakes, Timothy D.; Azevedo, Liane B.; Romanov, Nicholas; et al. (2003)(2003)

Purpose: compare the biomechanical changes during 3 different foot strike patterns

Methods: 20 runners instructed in mid foot and Pose running. Clinical gait analysis and biomechanical variables compared.

Results: Pose stride lengths

vertical displacement

vertical impact force

eccentric work in knee

eccentric work at the ankle

POSE METHOD® POSE METHOD® OF RUNNINGOF RUNNING

There is an ideal position “pose” for running. There is an ideal position “pose” for running. Line goes from head-shoulder-hip-ball of foot. Line goes from head-shoulder-hip-ball of foot. Running mechanics:Running mechanics:

Mid-foot striking pattern (ball of foot), below COMMid-foot striking pattern (ball of foot), below COMVertical foot removal immediately after foot Vertical foot removal immediately after foot strikestrikeMinimal use of armsMinimal use of armsSmall forward trunk lean Small forward trunk lean

Romanov & Robson, 2003Romanov & Robson, 2003

www.posetech.com www.posetech.com

Chi Running® and Chi Walking®Chi Running® and Chi Walking®

It encourages runners to lean forward from the ankles.It encourages runners to lean forward from the ankles.

The legs start in a run powered by gravity instead of muscles.The legs start in a run powered by gravity instead of muscles.

One of the best developed learn to run programs offered.One of the best developed learn to run programs offered.

www.chirunning.com www.chirunning.com

Goal: make running easierGoal: make running easier

Built on the principles of tai chiBuilt on the principles of tai chi

Focus on good postureFocus on good posture

Running InjuriesRunning Injuries

Predisposing Factors:

Anatomy: No relationship between an “installed” anatomical peculiarity and a pathology of the LE

Except: Significant asymmetry (>2cm) or after acute change

Biomechanics: No relationship between an “installed” biomechanical peculiarity and pathologies of the LE

Except: above + significant weakness which changes entire LE biomechanics.

New to running and fitness

Previous history of injuries(2010- Buist, 2008- Buist)

Barefoot vs. ShodBarefoot vs. Shod

Acute vs. Chronic Acute vs. Chronic PFS

(load)

Neuro-proprioceptive taping; myofascial releaseOf lateral structures

Glute strengthening;Eccentric loading – step downChange running form

ITBS

(Repetition)

Neuro-proprioceptive taping; myofascial release of lateral structures; AP fat pad; foam roller;

Glute strengthening; single leg squats; hip hikes; airplane ex. Interval running

AT

(load)

Unload (heel lift; no hills/speed); protect (friction)Calf stretching if neededAP; US; ART

Eccentric loading;Return to run (run often/daily)

MTSS

(load)

Unload (no hills/speed)Myofascial release; US; AP;Taping

Eccentric loading; IMF strengthening; calf stretching as needed