Introduction
Management of running injuries can be a difficult process. The key to developing a comprehensive plan of care for any runner is to systematically examine all the contributing factors that may be involved. This will ensure that you address not only the source of the symptoms but the primary problems as well.
Rehabilitation of Running Injuries
A holistic approach is required to fully rehabilitate any sports injury. This approach should address all the intrinsic and extrinsic factors contributing to the injury. Rehabilitation in Sport includes the following fundamental components
- Pain Management
- Flexibility and Joint ROM
- Strength and Endurance
- Proprioception and Co-ordination
- Functional Rehabilitation
- Use of Orthotics
- Psychology of Injury
Running Biomechanics
Inefficient running biomechanics play an important role in the development of running injuries [1]. If a runner has poor kinematic patterns and running form, it will affect the body’s ability to absorb external forces and put them at risk of developing overuse injuries. [1][2].
Assessment of running biomechanics with 2D or 3D video on a treadmill has shown to be an accurate way of analysing running style [3].
Developing a Plan of Care to Address Running Biomechanics
Step 1 – Understanding Training and Injury History- (Subjective Exam)
A detailed initial interview with a patient is extremely important. A thorough history will allow you to fully understand the entire scope of the problem and exclude any serious pathology.
There are many risk factors to investigate when it comes to running injuries. Questioning around modifiable factors such as running distance, frequency, pace, intervals, diet, hormonal problems or changes, use of orthotics, running surfaces, warm-up, stretching and physiological aspects should be done [2]. Non-modifiable factors such as age, sex, height, experience, previous injury and general health are equally as important to investigate[2]. A systematic review conducted in 2016 found that the biggest risk factor for developing a running injury is a history of a previous injury[2]. Incomplete rehabilitation of a previous injury potentially results in biomechanics faults. This could be the cause of developing further overuse injuries.
Asking about the runners short term and long term goals ensures that you and the runner are aligned in your treatment plan and progression thereof.
Step 2 – Mobility and Motor Control Deficits- (Physical Examination)
A physical examination is important in any symptomatic patient to comprehensively assess the entire body to be able to accurately diagnose and treat them. Posture, joint range of motion, neural mechanosensitivity, muscle strength are all important aspects to examine. It is important to assess a runner’s mobility and motor control as these would be factors that could lead to biomechanical changes in their running styles.
Movement screening involves analysing a series of basic functional movements, with the purpose of identifying any motor control deficits or mobility deficiencies. The Functional Movement Screen is an example of a movement screening tool that was developed with the goal of identifying movement pattern deficits to try and predict future injury. While it is a reliable tool its validity in terms of predicting future injury has not yet been established [4]. Instead of using the screening tools to try and predict future injury you can use them to assess a patients mobility and motor control deficits that are contributing to an existing injury.
Before watching them run you can perform a movement screen. This allows you to systematically examine the exact faults in mobility or motor control that are contributing to their symptoms. Basic movements such as toe touch, back bend, rotation, single leg balance and squat can be assessed and then components of each movement analysed in more detail [5].
The videos below show some examples of various movement screening tests
Blog based on Step 3 – Analyse Running Form
The next step to identifying the source of symptoms as well as contributing factors is to assess the runner’s form. Assessment of running biomechanics using a treadmill and 2-D video analysis is a reliable means of analysing running kinematic patterns[4][6].
Having already assessed their mobility and motor control deficits will help you to determine the reason why they have adopted a specific running style or alternatively if their running style is contributing to their mobility or motor control problems.
Some common running styles seen are as follows: [5] By doing a thorough interview to understand the history, a comprehensive physical examination to determine all the mobility and motor control deficits as well as a running gait analysis you should then be able to develop a comprehensive plan of care. This should address every aspect of the runner’s problems so as to treat them holistically and ensure long term recovery.
The goal of developing a plan of care is to individualise the plan to the runner’s specific examination findings. Every plan will look slightly different and take into account each aspect of that specific runner’s history and biomechanics.
In Ari Kaplan and Doug Adams Running Course[5] they propose a 5-part treatment plan that addresses the following aspects: Mobility, Stability, Form Drills, Gait Retraining and Flexibility. The focus on each area and within each area will differ in every runner. The aim is to use your assessment to centre treatment around the specific aspects that address the runner’s unique problems.
A dynamic warm-up is an initial component of a training programme. Incorporating dynamic stretches into any pre-activity warm-up is superior to static stretching although the physiology behind this is still uncertain[7]. Manual soft tissue release can also be incorporated as part of a warm-up as it has been shown to improve mobility without compromising muscular activity[8].
Static stretching, PNF and dynamic stretching have all been shown to positively influence joint range of movement[9]. Static stretching and PNF may affect immediate performance and should not form part of the warm up. It is recommended that they are performed either well before the commencement of exercise or at the end of the activity[9].
There is no “standard” mobility programme for runners and your assessment findings will guide your prescription.
Step 4 – Create a Comprehensive Plan of Care – (Treatment/ Intervention)
1. Mobility
2. Stability
Addressing motor control and muscle strength impairments by means of an exercise programme has consistently shown to be effective in improving running economy and performance in middle and long distance runners [10].
The therapist will have identified any motor control or strength deficits during their assessment and an individual programme addressing the runners needs can be developed.
Mobility and Stability are important aspects to address when rehabilitating a runner. An example of a programme to address a specific movement dysfunctions can be found
3. Form Drills
The aim of form drills when rehabilitating a runner is to help improve motor learning and help with gait retraining. Form drills can help to isolate specific components of running and facilitate a change in the way the runner is moving.
There are many form drills that can be incorporated into a plan of care and again this should be individualized to the runner’s specific needs.
Some Examples of Running Drills (see video below)
- A-Skip,
- B-Skip,
- High Knees,
- Butt-kicks (two variations),
- Straight-leg bounds
- Carioca.
4. Gait Retraining
Gait retraining has been shown to be effective in addressing key biomechanical factors that are associated with running injuries such as ground reaction forces, energy transfer at the knee and ankle as well as centre of mass excursion [11][12][13][14]. There is good carryover from a gait retraining programme with runners maintaining the changes even after 1 month follow up [12][15].
A major component of gait retraining is looking at cadence or step rate.
Running Speed = Step Rate x Step Length.
There has been a lot of research done around cadence and its impact on running biomechanics. There is no specific cadence that has been shown to be ideal however studies show that even a subtle increase in cadence whilst maintaining a constant speed can improve running biomechanics significantly [16][15][14]. A 10% difference is enough to change forces experienced through the knee [16] and does not affect running efficiency [15]. Increasing step rate while maintaining a constant speed reduces step length, vertical oscillation, ground reaction forces, impact shock as well as reduces the energy absorbed at the hip, knee and ankle[16]. All of these factors are key biomechanical components that contribute to lower limb injuries in runners such as tibial stress fractures and anterior knee pain.
It is, however, important to note that most of the studies on gait retraining have been done in injury free populations.
Gait Retraining Corrections to Try: [17]
Important note: caution should be taken in changing the biomechanics of runners, particularly with high-performance athletes, if you are inexperienced in doing so[5].
The Overstrider
- Increase cadence[13]
- Encourage foot to land underneath their body
- Encourage softer landing
- Encourage shorter steps
The Collapser
- Use feedback (verbal/ visual) to maintain a level pelvis
- Encourage knees to stay apart
- Increase Cadence[13]
The Bouncer
- Increase cadence [13]
- Encourage softer landing
The Weaver
- Encourage a slightly wider base of support[5]
- Run along a straight line and make sure feet are on either side of line
The Glut amnesiac
- Encourage more trunk flexion whilst running (may need to strengthen first to achieve this)[5]
5. Flexibility
Post running flexibility will potentially cover the same mobility impairments as addressed in the initial dynamic warm up. Static stretching, PNF and dynamic stretching have all been shown to positively influence joint range of movement. In a post-workout scenario, you could incorporate a more static stretching or PNF approach [9].
Conclusion
Rehabilitation of Running Biomechanics is a complicated process that requires a comprehensive assessment and then a detailed plan of care, individualised to the findings on examination.
Resources
Running retraining for patellofemoral pain SMA symposium with Dr Christian Barton
Gait Training for Runners with Richard Diaz
References
- ↑ 1.01.1 Van Der Worp MP, Ten Haaf DSM, Van Cingel R, De Wijer A, Nijhuis-Van Der Sanden MWG, Bart Staal J. ↑ 2.02.12.22.3 Hulme A, Nielsen RO, Timpka T, Verhagen E, Finch C. ↑ Souza RB. ↑ 4.04.1 Bonazza NA, Smuin D, Onks CA, Silvis ML, Dhawan A. ↑ 5.05.15.25.35.45.5 Ari Kaplan and Doug Adams. Common Running Errors Course slides, Physioplus, 2019
- ↑ Dingenen B, Barton C, Janssen T, Benoit A, Malliaras P. ↑ Opplert J, Babault N. ↑ Silva P, Lott R, Wickrama K a S, Mota J, Welk G. ↑ 9.09.19.2 Behm DG, Blazevich AJ, Kay AD, McHugh M. ↑ Blagrove RC, Howatson G, Hayes PR. ↑ Schubert AG, Kempf J, Heiderscheit BC. ↑ 12.012.1 Crowell HP, Davis IS. ↑ 13.013.113.213.3 Heiderscheit BC, Chumanov ES, Michalski MP, Wille CM, Ryan MB. ↑ 14.014.1 Willy RW, Buchenic L, Rogacki K, Ackerman J, Schmidt A, Willson JD. ↑ 15.015.115.2 Hafer JF, Brown AM, deMille P, Hillstrom HJ, Garber CE. ↑ 16.016.116.2 Schubert AG, Kempf J, Heiderscheit BC. ↑ Enhance Running. Running Video Playlist. Available from: function gtElInit() { var lib = new google.translate.TranslateService(); lib.setCheckVisibility(false); lib.translatePage('en', 'pt', function (progress, done, error) { if (progress == 100 || done || error) { document.getElementById("gt-dt-spinner").style.display = "none"; } }); }
