You Got A Running Stride Analysis. Now What?

So you went to the physio and had your running stride analyzed. Maybe they filmed you on a treadmill? Or they hooked you up to a few sensors and watched you run down a track? Now that you have been videotaped, photographed, and are probably super self-conscious about your running form, it is time we tell you what to do about it all!

Here are a few case studies of some runners battling common injuries, what we saw in their stride assessments, and what we did to address these issues.

Case #1: Runner with Knee Pain

A 25-year-old woman started feeling right knee pain while training for a May half marathon. The pain was present for 3-4 weeks before her physiotherapy appointment. Her doctor diagnosed patellofemoral pain in her right knee, and prescribed physiotherapy. During her subjective interview with the physiotherapist, she reports that she has done half marathons before, but has been increasing her weekly mileage for an upcoming fall marathon.

Step 1: Objective examination and testing

During her objective exam, we found that she had weakness in her gluteus medius and gluteus maximus (the butt muscles). Testing revealed weakness in her deep core muscles. She is fairly mobile, with no real flexibility deficits. The range of motion in her hips, knees, and back were all within normal limits. I had her do a  two-legged squat. Both of her knees went into a little bit of what we would call a valgus positioning (knees coming closer together during the squat). This was further amplified when I had her do a one-legged squat, with more valgus positioning and inward rotation of her thigh.

Step 2: Running assessment

During her running assessment, a few things stood out to me right away. Most noticeably, her running looked almost bouncy or springy. That’s a sign of over-striding. Much like her squats, she also had increased hip internal rotation and valgus posturing while she ran. Whenever her left foot struck the ground, her right hip dropped, indicating weakness in her gluteals. She had good hip extension, no limitations there. I had her count her cadence (steps per minute) and it was in the low 150s. This is relatively low and likely due to her tendency to over-stride.

Step 3: Recommendations for improvement

So what did we recommend to improve her stride and hopefully get her running pain-free? To work on her gluteals, I had her start with a home program of one-legged bridges for her core and gluteus maximus, and clamshells for her gluteus medius. For her core, I had her work on isometric contractions of a deep abdominal muscle called the transverse abdominis. This contraction is the baseline for a series of movements that we incorporate to progress strengthening of these deep abdominal muscles.

Running-wise, she had already taken time off. We decided to have her ease back into running, but this time, I wanted her to be more aware of her cadence. “Ideal” cadence for many runners will be between 170-180 to avoid over-striding and the injuries that can come with it. If you want to work your way up, you can’t just jump to 180 steps per minute right away, and it may not be necessary to get all the way up there in every case. 170-180 is just a guideline. We believed that even a small increase in cadence would help her shorten her stride and help her to run a little “softer”, so we had her increase her cadence by about 5%. This would put her in the low 160s. We asked her to check in on her cadence for a minute every now and then while she was running. If we found she was running pain-free with this new cadence, there would be no need to increase it any more. And indeed, once she got into the low-mid 160s (and with the other exercises we had her do), she was able to run pain-free.

This runner was good about easing back into running, not over-doing it and interspersing walk intervals as needed. She also did some cross training with cycling. She stuck with her home exercises and we progressed her gluteal, hip, and core strengthening in future sessions. After a few weeks of run/walk intervals, she was able to go for 2-3 mile runs without any pain. At this point, we thought she didn’t need to come in anymore; we would monitor her progress as she increased mileage and continued her exercises at home. I touched base with her a few weeks later and things were still going well. Later, she even completed the half marathon she was training for without any knee pain and completed her first marathon in the fall.

Case #2: Marathoner with Chronic Plantar Fasciitis

This patient is a 30-year-old woman with chronic plantar fasciitis pain in her right foot. She had previous history of plantar fasciitis in her left foot. Her plantar fasciitis has historically correlated with an increase in mileage, and this time it is no different. The pain started while training for a marathon. It started with classic plantar fasciitis symptoms, like pain with the first steps in the morning. Typically running was not too bad: usually it hurt for the first few minutes, but was fine once the tissues warmed up. However, her foot would tighten up again after running and feel sore later in the evening. She taped it, bought new inserts for her shoes, bought new running shoes, iced her foot, and stretched her calves regularly. This seemed to keep it at bay and she got through the marathon well with the foot taped up. With the tape, she did not feel any discomfort while running.

After the marathon, she significantly decreased her mileage for a few weeks, running at a comfortable pace. She had not been taping her foot. The pain would return after she ran and first thing in the morning. She took two weeks off of running to see if this would help. Once she tried running again, the pain returned and seemed to be at the same intensity, or even a little worse.

Step 1: Objective examination and testing

Again, we started with objective examination and testing. We found her gluteus medius muscles were very weak. Core strength was pretty good. She had tight hip flexors and calf muscles. Her ankle was quite limited in dorsiflexion (upward flexion of ankle) range of motion. She has relatively normal arches, but has a tendency to stand more on the outside of her feet. Her two-legged squat looks pretty good (she is a PT and knows she is being observed on her form!). During her single-leg squats on the right leg, I noticed some opposite-hip drop and a little valgus.

Step 2: Running assessment

She did not think her running form was too crazy before going into the assessment, but we found several things that  she could work on! Looking at her from the side, we saw that her hip extension was limited during the terminal stance phase of her stride, meaning right before she pushed off the ground. To make up for this lack of hip extension, she increased the extension in her lower back. She didn’t have back pain, but this kind of compensation often causes low back pain in runners. Limited hip extension can be caused by tight hip flexors.

She excessively flexed her knees when she landed, causing too much vertical motion in her stride. We measure this by looking at knee flexion and seeing how much change there is in head movement up and down. This excessive knee flexion indicates a quadriceps-dominant runner, and may be why she does not extend her hip back far enough. Quadriceps-dominant runners, as the name implies, have quads that are doing most of the work during their running stride, while the hamstrings and glutes are not working as hard as they should.

Looking at her from the back, you can see a few things, as well. She has what we call a scissoring gait, or feet that cross her midline. Imagine running along a straight line on the road, normally your right foot would land on the right side of the line and your left foot on the left side of the line. This patient’s right foot landed toward the left, and vice versa. This is usually an indication of weak hips (we already know she has weak gluteus medius muscles from earlier manual muscle testing) and tight adductors (inner thigh muscles).

She has a little bit of hip drop, too, further demonstrating that her glutes are weak. She is also limited in thoracic spine (upper back) rotation. Her cadence is in the mid to high 170s, so we don’t need to work on that.

Step 3: Recommendations for improvement

So what do we do to help her out?

First we revisited our old friend, clamshells. Seriously, if everyone did clamshells, I might be out of a job. There is a progression we utilize for clamshells, either via changing foot position or adding resistance from a band. Other gluteal strengthening exercises we prescribed included: band walks (with band around the feet to further activate gluteus medius), and single leg bridges for gluteus maximus. Strengthening the gluteals should help with the scissoring gait pattern, along with stretching the adductor muscles.

To address her limited hip extension, we did a few things. First off, we needed to stretch her tight hip flexors. There are several different ways to stretch the hip flexors, such as a lunge stretch or dangling the leg off of a table. Loosening these up will improve mobility, allowing her to extend back further and lessen pressure on her lower back.

Since she is so quadriceps dominant with her running, we want to do more to strengthen her posterior chain! We’ve addressed her gluteal muscles already, but this is where some hamstring strengthening can be helpful, too. Bridges and single leg bridges strengthen both glutes and hamstrings. Some of my other favorites for hamstrings include deadlifts, lunges, and single-leg deadlifts.

For her tight thoracic spine, we can work on joint mobilizations in the clinic. We also taught her some stretches and movements for self-mobilization. One that I like is called “threading the needle”: get down on all fours and place one hand behind your head. Twist your torso so the elbow rotates toward the steadying arm, twist back all the way up bringing that elbow up to the sky and repeat. Don’t worry, I’m including a picture so you can see what I’m talking about! In addition, I love using foam rollers for thoracic spine mobility. I will leave a few pictures of those exercises, as well.

Finally, we had her work on stretching her tight calf muscles.

We put this runner in a walking boot for 3-4 weeks to take pressure off of her foot while she was standing at work. This really helped lessen the pain. She continued running with the tape on her feet to put the plantar fascia in a shortened position. We also utilized a treatment called ASTYM (augmented soft tissue mobilization) to break down abnormal tissue texture in her gastroc, Achilles, and into the plantar fascia. For best results, ASTYM should be done 2-3 times per week and followed up with extra stretching on the days it is done. After running, she iced her arches and heel to help with inflammation. NSAIDS and steroid dose packs can be helpful as far as medication goes to knock down inflammation,  but not as helpful as unloading the foot.

It was slow going, but she got better. Plantar fasciitis is one of those conditions that can take forever if you do not get it taken care of right away. We often ignore the symptoms, thinking it will get better on its own. This is one that I would advise to not mess around with! It can become chronic and terribly difficult to get rid of!

Case #3: Runner with low back pain

Our third patient is a 35-year-old man who experiences low back pain while running. He has recently gotten back into running after a few years away from it, and has been increasing his distances gradually. He has no other significant history of any running injuries, but he has sprained his ankle several times playing soccer.

Step 1: Objective examination and testing

For our objective findings, I found that he stands with a more pronated foot posture. His arches are on the flatter side, but not excessively so. When he squats, his back heels lift up some, indicating tightness in his calf muscles. Other than this, his two-legged squats look normal. I noticed some hip drop when he did one-legged squats when testing each side.

Ankle mobility testing showed that patient was loose in an inversion motion (ankle rolling in) because of his ankle sprains, but tight in dorsiflexion (probably partially because of those tight calves). He was tight in his hip flexors and hamstrings with testing, as well. Since his low back is sore, we want to check the range of motion and accessory mobility (movement between vertebra) of his spine. We tested his lumbar range of motion in standing. It was overall within functional limits, but he had pain with extending his back. This pain was in the lowest part of his back just above his tailbone, right side more so than the left. I checked his thoracic range of motion in sitting (to keep the lumbar spine from getting involved). He was tight in thoracic extension and rotation. As far as accessory mobility goes, he was tight in his lower lumbar facets (where the joints of the vertebra meet), right more so than left. He was pretty stiff in his thoracic spine, as well.

Step 2: Running assessment

During his running assessment, there were a few things I noticed from the side. He is another one who runs with limited hip extension. This was expected, given his hip flexor tightness. Because of this limitation in hip flexion, he, like the patient in Case 2 above, is extending his lumbar spine to compensate. This is probably what is causing pain in his lower back.

From the back view, his opposite hip does drop slightly during the stance phase, indicating that, yes, he does have some functional glute weakness. Bring back those clamshells, walking with theraband, bridges, and all those wonderful exercises! He is also limited in his thoracic rotation. He would be a good one to work on the thoracic mobility stretches in quadruped and on the foam roller. Manipulation might also work on the thoracic spine.

As far as his feet go, I did not notice any significant overpronation during his stance phase. Remember, pronation itself is a natural part of foot mobility! Problems arise when you stay in pronation for too long and then push off of a flexible foot posture rather than a more rigid, supinated posture. He is a heel striker, which is very common. At least 75% of runners are heel strikers. Heel striking is not evil, it’s really about how the whole body moves.

Step 3: Recommendations for improvement

For lower back pain, there are several different stretches and manual joint mobilizations we can use to create some relief. We also must stretch his hip flexors! There tends to be a diagonal pattern of tightness and weakness for many people. One line can be drawn through tight hip flexors and tight lumbar extensors and the other can be drawn through a weak core and weak gluteals! Working on core strengthening, specifically activating the transverse abdominis and lumbar multifidi muscles, is important to provide stability to the spine and decrease overuse of the lumbar extensors. We can do ASTYM and soft tissue work on the lumbar extensors.

Since his calves were tight, he benefitted from some good stretching to this area and posterior mobilization of his ankle joint.

With postural awareness, manual therapies, and flexibility and core strengthening exercises, this patient did well and eventually ran pain-free.

Stride analysis looks at the whole chain

That was a long post, huh? Running analyses are great because they allow us to look at a person as a whole! When someone comes in with a knee problem, we would be doing them a disservice to just look at the knee. Problems anywhere along the chain can lead to issues elsewhere, because as we’ve talked about before on Salty Running, it’s all connected! Sure, I’m biased, but it can be very helpful to see a physical therapist for an evaluation and a running assessment before an injury becomes chronic!

If you have had a running assessment, what did you end up having to work on?

A born and raised Hoosier running to stay sane. I've done 5Ks to marathons, but am currently running to enjoy running. I'm an orthopedic physical therapist, with clinical specialization in treating people with vestibular disorders. Other things I specialize in? Knowing the lyrics to every Backstreet Boys song and being an awesome cat mom! Living with Crohn's disease, but trying to show it who really is the boss.

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