Treating Runners: Easy as 1,2,3

Treating runners can be complicated, but it doesn’t have to be. The biggest issue with treating them is that the person working with an injured runner is often an expert at one thing. A running coach is incredible at training plans and often can identify flaws in form, but what if that flaw in form is the result of a mobility restriction?

The rehab clinician is often amazing at identifying mobility restrictions, but many are not trained to identify abnormal running mechanics.

There are people who are trained in both, but they often do not use the tools to identify finer flaws in running form.

I had a recent case which fell in line with this pattern. I saw a former college runner who was running 50-80 miles/week, but had not run more than 10 minutes in 18 months. He had developed the dreaded IT Band Syndrome and was frustrated and felt like he needed to give up his career in running in only his mid 20’s. He had already seen multiple people from many professions. Each individual helped with something. The podiatrist gave him orthotics. The PT worked on his single leg squat. His running coaches cued his form. There were small improvements, but nothing substantial.

When I looked at him, I found he had only small limitations in glute strength and IT Band flexibility. The previous PT had done a great job with this already! 

While every runner’s issues have variations, there are 3 keys I often see with a runner who has not recovered. These 3 key factors could have been used with this runner and would have helped prevent this injury lasting 18 months. I think each of the practitioners working with him were capable of incorporating this, and with a little training, everyone reading this post can as well. The 3 key factors are below:

Key Factor # 1: Don’t Miss a Mobility Restriction Masquerading as a Motor Control Issue

One of the things I typically check is a single leg squat. It was poor and the runner told me this had been a large focus previously, but little improvement was seen. With so much focus, why would this not have been fixed??

The patient’s demonstration of a single leg squat was poor as his hip rotated inward and his knee collapsed. The immediate reaction is, “Weak Glutes!” That is a great pick up and often true! The issue is that we can’t assume that just because he collapses inward, his glutes are weak (or even that his motor control is poor). There is ample research correlating the two, but this is not the case with every runner who walks in our door. He may have had weakness or a motor control issue at some point, but by the time he got to me, this looked great. His single leg squat was still poor however! Why is this?

He had a mobility issue masquerading as a motor control problem. The patient’s ankle and calf flexibility were extremely poor. When he performed a single leg squat, he ran out of ankle dorsiflexion and collapsed in at the ankle. As this moved up the chain, his knee also caved in. It was his body’s compensation for limited dorsiflexion ROM.  His glute was working fine! The culprit was down below at the ankle!

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Key Factor #2: We Often Watch What We Want To (Confirmation Bias)

His running coach had been working primarily on speed and building his endurance and had thought his running form looked good. Again, this is great!

I had the patient get on the treadmill and watched. I checked the most typical things that I always watch first. 

• Was there collapse in at the knee? Maybe slightly.
• Was there pelvic drop? Not that I could see.
• How was his cadence? Looked slow, but I didn’t count right away.

Here’s the thing. I work with a lot of runners, but college (and beyond) running coaches are far better than me at working with runners’ form. They understand training plans and they understand drills. They do this every day of their lives! But what I lack in their amazing expertise in these areas, I can make up for with recognizing my own limitations! I can’t see what I think I can with only the naked eye. Here are the views that I took with my phone. I did not immediately pick up on these issues when I was watching full speed and checking for what I expected: pelvic drop and collapse at the knees.

In the picture to the right you will see the red lines which show that he is running with his body in the same place as he strikes his left foot then his right foot. The yellow line in the picture shows where his feet are striking. It’s as if he’s running on a tight rope! His base of support should be wider and this can place abnormal stress on the lower extremities. I may have noticed this eventually in real time, but not to this extent. How significant is this though? Let’s look below.

In the picture to the left, notice the green line which borders his lateral right knee, the location of his pain for the past 18 months. Now look along the green line and see how far it is away from his foot. This is substantial when you consider he is doing this every step for 50+ miles/week! That is a lot of tensile stress the lateral structures are going to experience.

Key Factor #3: It’s One Thing to Say, It’s Another to Show!

The runner previously worked with a fantastic therapist that I know very well. He worked with Division 1 Cross Country Coaches who were fantastic. When I asked him about his running form, he was very confident that there were no issues. Why would there be? He had worked with great coaches!

It wasn’t until I took out my camera phone and showed him that the light bulb went off for both of us. No one had videoed him prior. It took only a few minutes for me to take out my phone and record him. I typically use a 3D Gait Anaylsis System for this (which takes about 15 minutes), but chose to use my phone for a quick illustration to him. The benefit I would have had of using the 3D system would have been that it would have calculated all of these measures (and much more) and provided me a report on his mechanics. Even better, once we start working on his gait retraining, I can use the system to provide biofeedback to quickly fix his running mechanics and allow him to return to a pain-free life! Additionally, I can track his progression and be able to document this to avoid questions from insurance companies!

The thing to remember here is that he thought his running form was perfect. If I hadn’t shown him, he would have been much less receptive to changing it. As soon as he saw it, he wanted to know what he could implement immediately to improve his running form. In my next post, we’ll talk about the cue I gave him to correct his running form.

These 3 Key Factors were instrumental in identifying how to fix 18 months of problems:

1)  Don’t Miss a Mobility Restriction Masquerading as a Motor Control Issue

2)  We Often Watch What We Want To (Confirmation Bias)

3)  It’s One Thing to Say, It’s Another Thing to Show

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