By: Josh Billings, PT, MPT, MedStar Health
As a Physical Therapist and Running Program Specialist for MedStar Health, I spend the majority of my clinical hours working with injured runners. Virtually all of them want to return to comfortable and healthy running ASAP; preferably sooner. Every injured runner wants to find out what went wrong and how to fix it. And if we can help make them a better runner in addition, all the better.
Most runners come to their PT evaluation with some sense of what may have caused the injury: a training error, new or less than ideal shoes, a weak spot, a tight spot; often some combination of all these things. A typical PT evaluation includes a physical exam to assess strength and mobility. This is where we find those weak and tight spots and may be able to prescribe corrective exercises to help improve them. For some injuries, that may be enough to get you back on track.
A quality Running evaluation will go deeper and could include some combination of:
Assessment of footwear and shoe wear pattern. Used running shoes can tell a loud story if you’re listening.
A thorough history that includes previous Running Related Injuries (RRIs), typical training (running volume, x-training, strengthening, mobility work, etc.).
Video Gait Analysis
While each piece is important and related, I find the Video Gait Analysis to be most important. How we run gives the most telling piece for which areas of the body may incur the most stress, and thus be most susceptible to injury. As noted above, many RRIs are due to a training error. Some are obvious, like the high school cross country athlete who didn’t run all summer and runs 30 miles the first week of practice in August. Most are much more subtle, like inadequate recovery between workouts or adding multiple new training components in the same week.
These important training pieces may point to why someone is injured. How you move shows where you are most susceptible to injury when something does go wrong.
Video Gait Analysis can take many different forms, depending on the software and technology used. A typical VGA will be 2-D with the ability to capture at 90+ frames/second of the full body from the side, rear and frontal views. The software will allow slow motion and frame by frame analysis, measuring joint angles. Other running related data such as cadence may be recorded as well. A Physical Therapist with specialized training in running biomechanics will be able to look at and analyze many things that could be less than ideal. For the purposes of this article, I will focus on the Big 3: overstriding, rearfoot motion and hip drop. Overstriding: This is viewed from the side and by measuring where the ankle is in relation to the knee when the foot first contacts the ground.
Overstriding is the general term for the ankle being well in front of the knee and is often characterized by a strong heel strike, sometimes with the knee fully extended. That said, this “typical” overstriding pattern has led to many runners believing that heel striking is inherently bad and increases injury risk. But it is very possible to land on the rearfoot (most runners do), but to still have a bent knee at Initial Contact and absorb impact quite well. It’s difficult to tell whether you are a true over-strider without some good video evidence.
Overpronation or Underpronation: Pronation is viewed from behind and is most easily thought of as how far the rearfoot tilts in as the foot moves through the stance phase of the gait cycle. A few degrees of pronation is very normal, but excessive pronation (thought of as tilting excessively inward or “the arch collapsing”) is linked to a number of RRIs such as medial shin pain, knee problems and plantar fasciitis. It is also important to remember that having too little pronation can be just as big a problem, though it is not observed as commonly.
Hip Drop: Viewed from behind and measures at the level of the pelvis during mid-stance of the gait cycle. Excessive drop generally indicates a weakness of the glutes. This is seen commonly in runners who don’t do any specific strengthening to target the glutes and/or don’t x-train or play sports that may involve more lateral agility that will naturally work the glutes more. This is an incredibly common gait abnormality and one that can set a runner up for several injuries: IT-Band Syndrome, Patellofemoral pain and Bone Stress Injuries, among others.
While there are more than a dozen other pieces we analyze, I start with these Big 3. If a runner demonstrates problems with any of them, we address them with a plan that may incorporate:
Corrective exercises
Manual therapy and modalities like electric stim with dry needling for tight spots
Modifying footwear - For overstriding and pronation issues (too much or too little) this is especially important • Drills to improve mechanics.
Education and recommendations on when and how to resume training. This may involve use of an anti-gravity treadmill to minimize impact forces and allow runners to continue training when they otherwise may be unable to.
In conclusion, there are a lot of components to an exam for an injured runner. The biomechanics are the most important piece to point them in the right direction for how to get healthy and stay healthy so they can train injury-free, continue improving and doing what they love. To request an appointment with a MedStar Health sports medicine physician, call 888-44-SPORT.
Author: Josh Billings, PT, MPT
Physical Therapist
Regional Director
Running Program Specialist
Josh received his BS in Biology from Susquehanna University in 1995 and his MPT from University of Delaware. Josh was a 2x All-State XC runner in PA and state runner-up in the 800. He continued as a middle distance runner in college and afterward ran a sub-3:00 Boston Marathon.
Professionally, Josh started the first Running Injury clinic in the Baltimore area and incorporates his manual therapy skills with video gait analysis and use of an Anti-Gravity Treadmill. In addition to his running and clinical interests, Josh is also the Regional Director of 6 MedStar Health Physical Therapy clinics in Anne Arundel County and South Baltimore.
