Wednesday, July 27, 2011

Should Runners Learn to Dance? Physical Therapy and Performance Implications (Part 2)

In Part 1, we discussed several observations involving the sports of running and dancing.  These observations lay the groundwork for this post, so if you have not read Part 1 yet, I suggest you at least skim it.

Now....some of you may be asking yourselves, "What do these observations mean to me as a runner!?"  Today I'd like to delve deeper into one of my methods for developing functional single-leg stance (adapted for runners from the Selective Functional Movement Assessment).  Remember, this method also applies to the early rehabilitation of dancers, so if you run by day and dance by night, listen closely!

First, let's take a look at dysfunctional single-leg stance:

Front view                                                      Back view

Do you see how this runner is leaning away from the leg on which he is balancing?  He is unable to stabilize his body through his trunk and lower extremity.  So, if you exhibit dysfunctional single-leg stance like the runner above, how should you go about developing a functional one?

As a sports physical therapist, my first goal is to help teach my patient the feeling of functional single-leg stance.  In other words, I use inexpensive tools to encourage the body to activate the required stabilizing muscles.  Check out the picture below.

                        Single-leg stance with trunk musculature activation**

**Take note of the 90-degree angle at the L hip and knee as well as the upright trunk position....think of trying to stay pencil-straight from your stabilizing (planted) leg to your head.  Proper positioning of the band involves hanging it around an object like a weight machine or a tree and pulling it towards your body with palms down.  Make sure that you have enough tension in the band.

I am having the patient use a band (can be a piece of Theraband or other stretch-like material) to facilitate activation of the trunk musculature.  One of the main reasons runners display dysfunctional single-leg stance is because they are not able to engage the trunk in concert with pelvic stabilizing muscles and the respective lower extremity.  If you utilize a band as illustrated above, you will notice that you can more easily maintain the single-leg stance position.  At that point, you are beginning to teach your body proper muscle activation patterns, which are extremely important for injury-free running.  How long should you maintain this position?  Enough time to challenge yourself.  Build up to 4-5 sets of 45-second bouts.  When you can maintain functional single-leg stance with the band for 45-seconds at a time repeatedly, retest yourself.  I'll bet that your once-dysfunctional single-leg stance is now functional = minimum of 10-seconds maintaining proper form without losing your balance.  Obviously, additional progressions for this functional movement exist, but the exercise illustrated above is the BASE for more advanced sequences.

Following development of functional single-leg stance, a series of low-level plyometrics is often initiated, beginning with double-leg hops and progressing to single-leg hops.  This portion of the exercise prescription following a running-related injury can be quite tricky and is best completed under the guidance and supervision of a physical therapist who specializes in treating runners.

If you have any questions or comments regarding the information just presented or a personal running-related injury question, feel free to contact me at or via DoctorJunes on Twitter.  I would be happy to help you in any way that I can.  And please, don't be like one of the dance accidents in the YouTube video below!

Wednesday, July 6, 2011

Should Runners Learn to Dance? Physical Therapy and Performance Implications (Part 1)

Runners and dancers -- two completely different types of athletes, right?  Think again.  Although formal dancing often occurs in an upstairs studio and running is performed anywhere from treadmills to trails, the two disciplines share some startling similarities.  Personally, I do not have any formal dance training unless you count the 5th grade ballroom dance lessons...thanks Mom and Dad!  I have much more experience working with and treating runners.  But as a physical therapist, I have worked with several dancers over the course of my career thus far, and I have made the following observations involving both sports:

1.) Dancing is a form of exaggerated running.  Running is an activity in which an individual is always in single-leg stance (one leg on the ground at a time) on one extremity.  In other words, one leg is on the ground while the other is in the air.  Dancing commonly involves leaping from one foot to the next; therefore, like in running, development of functional single-leg stance (see pictures below) is an extremely important element of a physical therapy plan of care for a dancer.

Front View                                                       Back View

2.) Development of the foot and ankle musculature and proprioceptors is vital to success.  A dancer who is weak in her foot and ankle complex will not be able to safely land while leaping.  Sports physical therapists see a fair amount of dancers with ankle sprains as a result.  The same principle applies to runners, particularly those who compete in off-road/track events like cross country and trail running.  Those readers who regularly run on trails can identify with this statement...strong and agile ankles can mean the difference between navigating that rock on the trail or sitting down on it afterwards with a bum ankle.

3.) From a performance standpoint, runners and dancers are always attempting to develop more powerful strides or leaps, respectively.  For runners, a powerful stride combined with an effective metabolic system is a deadly weapon.  Have you ever seen a professional dancer leap across the stage?  What a graceful display of true athletic power.  Should you be performing exaggerated running aka bounding as a part of your comprehensive training program?

Just a few casual observations to consider.  Runners can learn from dancers and vice versa.  Actually, I have known a few individuals who have excelled at both disciplines throughout adolescence.  In addition, I will go one step further and state that a common paradigm exists for treating running and dancing injuries.  Will the final stages of rehabilitation be different?  Absolutely.  But many similarities will exist in the earlier stages in terms of functional exercise.  In my next post (Part 2), we will explore how some of these observations and concepts relate to the treatment of running and dancing injuries.  These implications will be useful for all runners who desire to decrease their incidence of future injuries.  Check back for more!

Monday, June 20, 2011

Physical therapists who always preach "more stability is better"....Are they really helping ALL runners?

I read an article in the magazine ADVANCE for Physical Therapy & Rehab Medicine the other day that had a great premise but was not very inclusive.  The article "Solid Footing" fell short in a few ways.  Read my published commentary below for my thoughts on the article.  I have also attached the link to the article + commentary for your convenience.


Gait analysis with high-speed video equipment is certainly a valuable tool when treating the injured runner.  This article hits that point on the head.  I disagree with a few of the other points presented, however.

First, if the runner is dealing with an injury that is a direct result of poor biomechanics, the first step of action is not always to provide him with the most support possible.  The symptoms associated with some injuries can change very quickly (for the better) when the source of stress is eliminated.  Such sources of stress include, but are not limited to, excessive pronation, heel striking when compared to mid-foot or forefoot striking, and significant peak hip adduction and hip internal rotation in stance.  As the authors stated, some runners may need more support initially, but what they failed to mention is that there are others who may benefit from less support.  For instance, a patient who is struggling with persistent knee pain may need to adjust his footstrike kinematics in order to eliminate the impact transient at initial contact.  Take a close look -- is the patient heel striking, contacting the ground significantly outside his center of gravity aka overstriding?  The proper way to eliminate that impact transient is not to provide him with a more supportive or cushioned shoe but rather to teach him how to contact the ground lightly underneath their center of gravity.  Applying this principle is quite simple.  Within the session, trial test barefoot running on a smooth grass or carpet surface.  If the patient experiences a reduction in symptoms, his injury is most likely related to footstrike kinematics, and a rehab program that involves performing balance activities and other stability exercises barefoot as well as short barefoot strides on grass (50-100m) will promote the development of a mid-foot or forefoot strike.  If the runner does not experience a reduction in symptoms, then maybe the clinician does want to look into stability shoes or even an orthotic….but not until barefoot running has been trial tested.  As physical therapists, we do not want to promote reliance upon external devices if they are not truly necessary.  The human foot and ankle is a marvel and was created to be functional on its own.  Physical therapists can help injured runners develop a healthier, more stable foot and ankle complex through proper exercise prescription.

Which leads me to my second counterpoint…why would the authors attempt to promote a forefoot strike among injured runners while they are wearing heavily cushioned and supportive shoes?  A high heel-forefoot drop, which exists in almost all stability shoes, encourages a heel strike.  The human body will take advantage of what it is given; therefore, if more cushioning is placed in the heel of a shoe, runners will initially contact the ground in that area of high cushioning.  Compare that to barefoot runners or those who run in more minimalist footwear.  They would not dream of heel striking as their calcaneus would be unable to repetitively bear such a load without bony injury.   So, if we try to have runners who are wearing heavily cushioned and supportive shoes forefoot strike, what are we doing?  We are certainly placing an awkward load on the Achilles tendon as it is in a shortened state throughout.  We should be encouraging the Achilles to lengthen through its normal range of motion so that more elastic energy can be stored before push-off in late stance.

These are just some thoughts for discussion and to highlight that there is more than one approach when an injured runner comes to a clinic’s door.  The clinic that considers both approaches is going to be the one that helps that runner return to running more efficiently and effectively.

Thursday, June 2, 2011

Elite Therapy's Couch to 5k Program = Success!

On April 5th, 2011, seven individuals braved the snow showers and 20-degree wind chills to gather at the Mansfield University track for the first training session of Elite Therapy's Couch to 5k Program.  One of them knew what to expect as she had participated in the Fall 2010 program; the other six were about to embark upon a new journey.  I remember telling the participants on that first day that the weather would only get better from there on out.  Boy, could I have been more wrong!  Those readers living in the Northeastern U.S. understand exactly what I mean by that statement.  We had a very rough spring....actually, I hesitate to call it was more like an extended winter with soaking rains.  Nonetheless, every Tuesday evening for eight weeks the Couch to 5k participants met for their weekly workout.

The first workout involved alternating 60 seconds of jogging and 90 seconds of walking for a total of 20 minutes.  Everyone was able to complete this first challenge -- some more easily than others, but they all knew that they had a long way to go before being able to successfully complete the Bridgman 5k on May 30th, 2011.  The Bridgman 5k has a reputation for being the toughest 5k in Mansfield, PA.  Although the first two miles are downhill and flat, the last mile is straight uphill....certainly not the easiest course for someone's first 5k.  But the participants persevered.  They slowly built up to being able to run 15-20 minutes continuously on the track, and that fitness was then taken to the next stratosphere once they began performing 20-30 minute continuous runs and interval workouts on hilly roads (total of three running workouts per week).  Come race day, they were ready to accomplish something that only eight weeks before their bodies and minds would have rejected at the mere thought.

May 30th was something the last two months had not been -- humid.  The participants were properly hydrated, however, and were not going to allow Mother Nature to detain them from reaching their collective goal.  After warming up, they toed the line with a definitive plan in their minds.  They were to pace themselves early in the 5k by relaxing on the downhill, allowing gravity to help take them down the slopes.  My hope was for them to save energy for the uphill last mile.  Knowing that this long hill would be the toughest point of the 5k, I stood along it and encouraged them as they ran by.  Each of the participants followed the plan to a "T" as they all finished between 31 and 45 minutes.  What a tremendous accomplishment for a group of individuals with little to no previous running background!

 Couch to 5k participants and me after the race

Bridgman 5k web site: 

The intent of Elite Therapy's Couch to 5k Program is to promote health and wellness in the Mansfield community free-of-charge.  Couch to 5k programs can be implemented anywhere though -- all you need is hard-working individuals who share a common desire to be healthier.  One of the most important aspects of the program is the team camaraderie that is generated.  The quote "Many hands makes light work" certainly holds true: the participants always found it easier to complete the workouts when they were running together with their teammates on Tuesday evenings.  Many of this spring's participants are already looking forward to Elite Therapy's next offering of the Couch to 5k Program.  Such anticipation to participate in another wellness program is a success in and of itself.  As a physical therapist, I know that I hope to continue helping individuals become healthier and reach their fitness goals!

Wednesday, May 18, 2011

Should ALL runners stop heel striking? Delving beyond footstrike....

In my last post, we discussed some of the underlying causes of running injuries -- poor biomechanics being one of them.  Today I'd like to delve a bit deeper into running biomechanics.

First, several different running footstrikes exist: heel striking, mid-foot striking, and forefoot striking.  If you went to your local 5k and observed the footstrikes of all the runners, you would quickly notice that almost everyone is heel striking.  Most recreational runners in the USA are heel strikers, which is likely a result of wearing cushioned shoes all their lives (with significant amounts of cushioning in the heels of the shoes).  Besides having poorly developed muscles within the foot, these runners might also overstride when they are running.  In many third-world countries where shoes are not as plentiful, individuals tend to be mid-foot or forefoot strikers while running.  Adoption of a mid-foot or forefoot strike is absolutely necessary because a barefoot calcaneus (heel) cannot repeatedly bear the load of our body at the point of initial contact; a healthy arch, on the other hand, is more than capable of bearing this load, which is what occurs during barefoot running.  Therefore, the availability and our choice of footwear certainly impact how we run.

Now, let's take a look at the differences between a heel strike and a mid-foot strike.  I've taken high-speed video using Dartfish software to provide you with a visual representation of each footstrike.  You'll notice in the top video (shod) that the runner contacts the ground first with the heel....and then rolls through onto his toes, at which point he pushes-off.  Conversely, in the bottom video (barefoot), the runner contacts the ground on the outside of his mid-foot....before flattening the foot and then rolling towards his toes to push-off.  Also, take note of where the runner's foot is landing in relation to his center of gravity (location of his pelvis) in each video.  A mid-foot strike forces the runner to strike more under his center of gravity than does a heel strike.  Why is center of gravity important in running?  Just like when we lift a heavy object from the floor, the point at which we initially contact the ground while running should be only slightly in front of our center of gravity (otherwise we are overstriding).  If it is not, we subject our lower extremities to significantly greater impact forces.  However, you can heel strike while still landing optimally under your center of gravity.  In this case, heel striking does not appear to be as bad as many make it out to be.  Unfortunately, very few runners are truly capable of heel striking without overstriding, which may be a result of our footwear.  On the other hand, it is nearly impossible to mid-foot or forefoot strike and overstride...hence the reason why many encourage a switch from heel striking to mid-foot or forefoot striking.  [Note: the current literature has determined that heel striking generates greater impact forces than mid-foot or forefoot striking even if you are wearing a well-cushioned shoe.]

Whew.  That is a lot for anyone to absorb all at once.  Contemplating these points though, many runners ask me whether they should switch from heel striking to mid-foot or forefoot striking.  My answer -- it depends.  It depends upon whether you are currently injured or running pain-free.  It depends upon your running goals.  It depends upon whether you are actually overstriding.  There are too many factors to consider to make a blanket statement for everyone.  What I will say is that many runners could benefit from including barefoot strides and drills on a smooth, grass field (excluding diabetics!).  This barefoot running will reinforce your "natural" biomechanics and help develop the many muscles in the ankle and foot.  You should use it as a SUPPLEMENT to your regular training regimen....just like you might supplement your training with strength training or core work.  Remember, build up slowly.  Start with one 50-100 meter barefoot stride and increase by one each week until you are running 8-10 barefoot strides total following a run.

Let me know your thoughts on the footstrike debate.  I'd be interested in hearing your experiences or stories regarding barefoot running.

Thursday, April 14, 2011

Always injured on one side? Think asymmetries.

First, your right achilles begins bothering you after a long run.  A few weeks later, your right hamstring starts nagging you in the middle of a faster track workout.  Three months pass, and then you begin having some pain on the front of your right knee a few miles into each run.  "What is going on?" you ask yourself.  "Why do I develop injuries only on my right side?"

Runners who ask themselves this question likely have gross or specific asymmetries.  In other words, one side of the body is stronger or more flexible than the other side....not necessarily at the site of the injury.  For instance, the runner in the above scenario might have weaker gluteal muscles and a slightly tighter calf on the right side when compared to the left.  Think of the human body as a kinetic chain: one chink in the chain can lead to a multitude of overuse injuries.  As a result, when a runner becomes injured, he or she (or the health care professional) needs to consider the significant effect an asymmetry can have on the body when it is subjected to a high training load.  I will even go one step further by saying that we should address asymmetries before an injury even surfaces.

Now, are asymmetries only tight or weak muscles?  Absolutely not.  We need to think about the way we move, sit, and perform basic tasks in everyday life.  Let's say that you squat to the floor to pick a piece of paper off the ground.  Do you notice that you bear more of your body weight on one side versus the other?  Does one heel come off the floor while the other remains flat?  How about the position of your knees -- are they both over your toes, or is one of them collapsing in?  Being able to perform a basic, yet complex movement like a squat with proper technique and body symmetry is an important factor for keeping injuries at bay.

Asymmetries are not the only factors that contribute to running injuries, however.  Training error (aka too much, too soon), poor running biomechanics, and symmetrical muscular imbalances (aka inactive or weak gluteal muscles) can all lead to a gradual onset of pain in one or more locations.  Therefore, the key to running injury prevention and recovery is identifying such deficiencies so that they can be addressed earlier rather than later.

Monday, March 14, 2011

Another great minimalist shoe - Merrell Trail Glove!

Recently, I decided to purchase a pair of the Merrell Trail Gloves.  I have worn a variety of minimalistic, "low-profile" shoes since December 2004 and continue to run by the mantra "less is more".  Although I recognize that such minimalist shoes are not for everyone, many runners could certainly benefit from supplementing their training with barefoot and/or minimalist running.  One of the key benefits of running barefoot or in minimalist shoes is the lack of (or very little) heel to forefoot drop.  Regular trainers have a greater amount of cushioning in the heel of the shoe than in the forefoot; as a result, the Achilles tendon is constantly in a shortened state throughout the gait cycle.  Why is this bad??  The same reason that high heels are terrible for a woman's feet.  A chronically shortened Achilles tendon does not produce the same amount of propulsion as does one of normal length.  Also, transitioning from high-heeled trainers to flats or spikes sans injury is much more difficult.  Training exclusively in more minimal shoes or including them in your training shoe rotation a few times a week can help you avoid these pitfalls.  Remember, as with everything, a VERY GRADUAL transition is necessary to avoid injury, however.

Anyways........the reason the Merrell Trail Glove is so special is because it has a zero heel-forefoot drop!  In other words, 12 mm of cushioning exists in both the heel and forefoot of the shoe = a flat shoe.  The 12 mm of cushioning provides sufficient protection from debris and rocks without taking away the ability to "feel" the ground.  Merrell also designed the shoe in such a way that runners could go sockless if they so desired.....they fit like a glove.  If you decide to go sockless, please make sure you wash them occasionally for your family's and friends' sakes!  Those runners currently wearing Vibrams will be happy to know that the forefoot of the Trail Glove is splayed to accommodate the toes.  This feature allows the runner to push-off the ground just as if he was running barefoot on a grass field.  Overall, the Trail Glove appears to be the first actual "shoe" that embodies the principles of Vibrams without the hippy flare.  A great minimalist shoe for any off-road surface!

Check them out, and let me know what you think!