You should probably never run in front of a physical therapist … unless you want to be judged. That’s right. I’m judging your running form. I am looking for reasons why you might end up being my next patient!
Not all of us have beautiful, perfect, elite running form. Usually we have imbalances or other issues with our gait. These may not cause any issues with shorter distances, but with increases in mileage or intensity, fatigue will exaggerate these faults. As a result, things might start to hurt.
Unless you run regularly on a treadmill in front of the mirror, it is likely you don’t see these little gait issues that can turn into big problems. This is where a running assessment comes in handy.
Before we watch you run, we do a lot of other stuff first!
At our clinic, a typical running assessment lasts around an hour. First, we’ll have you fill out paperwork before the session. This gives us some insight on troublesome areas and how long you have been dealing with your injury or issues. We want to know if you have been running long, whether you have increased your mileage, what surfaces you run on, and your shoe situation. Prior injury history is helpful. From this subjective information, we start to formulate some ideas about specific tests for issues we want to look at more closely.
After the paperwork and an initial chat are done, we move onto what we call the objective part of the exam. This is where we take measurements, test your strength, and look at your mechanics. We like to do this before we dive right into having you run, as it tells us why you might move in the certain patterns that you do.
Here’s what we’ll look at:
- Your posture in standing and sitting.
- The strength of your lower extremities, especially the core, hips, and gluteals. Weakness in these areas can cause dysfunction down that lower extremity chain. For example, weakness in the gluteus medius muscle (a common problem for many people) can lead to excessive inward rotation of the thigh (internal rotation) and inward movement of the knee (valgus), leading to knee pain.
- Hip flexibility and range of motion are important to address, and we have to look at this statically and dynamically.
- We are going to check your foot and ankle mobility. Are you pushing off of a rigid foot or one with too much mobility?
- We want to know what your foot posture looks like. You’ve probably heard the terms pronation and supination, and these are things we take into account. Ultimately, we are looking at these things as part of your shoe prescription. Research is showing now that running with the shoe that feels the most comfortable to you is typically the best bet. Still, we have often seen runners wearing a shoe that is contributing to their injury and thus can be considered the wrong shoe. Sometimes runners have an ok shoe, but are wearing an inappropriate size: shoes that are too big or too small can also affect your gait and cause problems.
- We want to see you perform squats, a single-leg squat, and even look at your form with some jumping and hopping. After all, running is a series of one-legged squats and jumps. With these activities, we are watching for lower extremity control. Do your knees cave in or out? Does your hip drop excessively on one side with a single leg squat?
Next comes the running part
The next step is to watch you run. Once you warm up (usually a few minutes) and get to your self-selected comfortable pace, we will utilize a tablet or phone to make a video of you running on a treadmill or runway with zero incline. We use the program Dartfish for this.
Programs like Dartfish enable us to watch the video in super-slow motion, step by step. You can create still-shots of important moments in the run. We film from several different angles and can zoom in and look at specific areas of the body while you are running. Views from the front, back, and side should be taken. The view from behind allows us to assess shoulder and arm swing, rear foot movement, and pelvic obliquity. You can look at knee adduction (valgus), arm symmetry, and in-toeing/out-toeing with the front view. Looking from the side allows us to look at hip, knee, and ankle extension and flexion.
Initially, we want to look for smoothness of movement and symmetry when observing the patient running. We are looking at the symmetry of arm swing and shoulder height. We look to see if you shift your hips symmetrically, and if there is any pelvic drop. How does your trunk move and what is your head position? How far apart are your feet when you strike the ground? We look at your stride length and which part of your foot strikes the ground when you hit the ground.
Dartfish and similar programs allow you to draw on the video and measure angles at the hips, knees, and ankles. This provides a great visual for patients. Quantitative measures of speed, cadence and stride length are easily obtained. Here are a few things that we specifically can measure utilizing some of these programs.
Ankle dorsiflexion at contact: Dorsiflexion is flexion of the foot in an upward direction occurring at the ankle. Measurements of dorsiflexion should be looked at with initial contact of the foot on the surface, mid-stance, and toe-off. Normal motion at foot strike should be between 10 degrees of dorsiflexion to 10 degrees of plantarflexion. Plantarflexion is movement of the foot with the toes pointed downward. A heel striker will be in more dorsiflexion, whereas a mid or forefoot striker will be plantarflexed. If someone has a tight Achilles tendon or calf muscles, this may limit ankle range of motion and can lead to tendonitis or other injuries in this area.
Knee Flexion at contact: This is best found just as heel contacts the ground and normal peak knee flexion should be between 15 to 40 degrees. The straighter the knee is upon impact, the greater the load to the knee and tibia (hello, shin splints!). Running with longer strides and faster speeds can create this decreased knee flexion. Stride length can be measured with running analysis programs.
Maximum Rear Foot Eversion: Foot eversion is the act of the heel turning outwards. It is best to look at this when the heel starts to lift off the ground. With normal mechanics, the rear foot should be vertical (or close to it) when the heel starts to lift as the foot leaves the ground. If the foot rolls out, or everts, too much, this is overpronation. Overpronation can lead to several of those dreaded overuse running injuries, like plantar fasciitis, patellofemoral pain (runner’s knee), IT band syndrome, or Achilles tendonitis. Note that pronation itself should not be a scary word, pronation is a normal part of the gait cycle and is needed with walking and running. With video analysis, you can also time the duration of pronation. Prolonged pronation can be problematic and this is more important to note than the degree of pronation. This would indicate that a runner is pushing off of their foot while it is still in a pronated position, making a less rigid/stable lever for push off.
Knee adduction in late stance: You want to take note of this one when the knee is at its lowest point during maximum knee flexion while the foot is in contact with the ground. This is a big one that we look at, and one of the reasons why we make you do all of those squats in our assessment. When the knee is flexed while the foot is on the ground, the patella should line up with the second toe. If it deviates too far inward or outward, this can lead to symptoms of IT band syndrome, Achilles tendonitis, and patellofemoral pain. Deviations can be due to overpronation of the foot, oversupination of the foot, and weakness of the gluteals and core muscles.
Hip motion – pelvic obliquity: A fancy way to describe hip drop! You can measure this by looking at the back of the runner’s hips, looking for the difference between the posterior superior iliac spine on both sides (these are the bumps just above your tailbone). During normal gait, the pelvis will drop 4 to 5 degrees on the swinging leg. If there is a difference in drop from side to side, it could indicate a difference in leg length, gluteal weakness, and dysfunctions in the spine and the hip.
Ankle Plantarflexion during push-off: Once again, we visit ankle plantarflexion, but this time when the toe is about to leave the ground. You can best measure and observe this by looking at a runner from the side. The ankle should flex downward between 20-30 degrees normally. Restrictions in this motion can lead to Achilles tendonitis, plantar fasciitis and even issues in the knee, hip, and low back. Other things that can limit ankle plantar flexion could include weakness in the calf muscles and stiffness in the first toe.
Hip extension – We look at this during terminal stance of the back leg. If a runner is complaining about back pain, this is something we want to look at. When a runner is limited in hip extension (bringing the leg back), they often try to compensate with excessive extension of the low back. These runners often benefit from core strength and stretching of tight hip flexor muscles.
The patient can also help us out during our running examination by counting their cadence. Cadence is the number of steps you take per minute. Optimal cadence for running is around 180 steps per minute, with ideal being more than 170 steps per minute. Ideal does vary slightly from person to person, and it will be different depending on what type of run you are performing.
We measure cadence by asking the patient to count the number of steps that they take on one foot in one minute. Take this number and double it, there’s your cadence. Someone who has a lower cadence tends to have a “bouncier” stride, with more rise from the ground. Runners with a lower cadence will often overstride. Those with a higher cadence usually overstride less, putting less stress and impact on the knee and hip.
If we think your cadence is too low and may be hurting you, the key to increasing cadence isn’t to jump to 180 steps right away. 180 steps per minute is not ideal or attainable for everyone. Increasing the steps per minute by about 5% can be a good way to ease into it. Many smart watches and GPS watches will provide your cadence for you. You can also use a metronome set to the beats per minute you desire. If counting really isn’t your thing, often we will use the cue to “run soft” as a means to decrease a runner’s stride length.
We will utilize all of these findings in our assessment to come up with a personal plan for you! Undergoing a running assessment can key in on things for you to work on to keep running healthy. A good assessment can help you become a stronger and more efficient runner, and help you decrease your risk of repetitive, overuse injuries.
Have you ever had your stride analyzed?
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