Rehabilitation of Running Biomechanics

Original Editor - Mandy Roscher Top Contributors - Mandy Roscher, Radhika Patel, Kim Jackson and Wanda van Niekerk
One Page Owner - Radhika Patel as part of the One Page Project

Introduction

Running related injuries (RRI) often have a multifactorial origin. They can be divided into personal, running/training, and health and/or lifestyle factors[1]. 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 cause as well.

Types of Runners

For setting up an ideal and custom plan of care, it is important to understand the type of runners. Runners can be classified based on their running distance, experience, and running objectives. Different types of runners are prone to different injuries depending on their duration, intensity, and frequency.

A recent narrative review (2020) suggests that
Injury risk may be greater for those who have recently started to run, those with sudden increments in either training load or intensity, and those training for longer distances, as these people need higher running volumes to prepare for races[2](p.9-10).
A systematic review and meta-analysis study (2015) provided the following definitions of different populations of runners[3](p.1145).
Track: sprinters - Track athletes competing in distances of up to 400 m
Track: middle-distance runners - Track athletes competing in distances of 800–3000 m
Track: long-distance runners -Track athletes competing in 5000 or 10,000 m races
Novice runners - Runners with no regular running experience within the previous year
Recreational runners - Non-competitive runners or runners participating in road races shorter than 10 km
Cross-country runners - Runners competing in cross-country races
Road: long-distance runners - Runners competing in races of between 10 km and less than a marathon
Marathon runners - Runners competing in a marathon
Ultra-marathon runners - Runners competing in races longer than a marathon

Factors Affecting Running Related Injuries (RRI)

There are various classifications for the factors affecting running injuries; the most common classification is:

  • Modifiable or Non-modifiable factors
  • Extrinsic or Intrinsic factor
  1. Physiological Factors (V02 max, Lactate threshold, and Running Economy)[4]: Modifiable, intrinsic
  2. Gender/Sex[1][5][6]: Non-modifiable, intrinsic
  3. Biomechanics[4][7][6]: Partially modifiable, intrinsic
  4. Footwear/Orthotics[4][7]: Modifiable, extrinsic
  5. Environment (Running surface; ground, treadmill, weather)[4]: Partially modifiable, extrinsic
  6. Training Variables (Mileage)[1][2][6]: Modifiable, extrinsic
  7. Nutrition: Modifiable, extrinsic

Prevalence of RRI

The incidence of running injuries is most common in the knee, ankle-foot, and leg (male and female runners)[5][8][9].

Specific to body part and pathology, Patellofemoral pain syndrome (PFPS), Achilles tendinopathy (AT), and medial tibial stress syndrome (MTS) account for the highest proportion[5].

A systematic review (2015) suggested that a history of previous injury and the use of orthotics/inserts are risk factors for RRI[1].

Provided below are running injury proportions (Figures 1-4) by gender, anatomical location, and specific pathology[5].

Running Biomechanics

Inefficient running biomechanics play an important role in the development and incidence of running injuries[10]. 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[11].

Assessment of running biomechanics with 2D or 3D video on a treadmill has shown to be an accurate way of analyzing running style [12].

Rehabilitation of Running Injuries

Management of running injuries is multifaceted. 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

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 [11]. Non-modifiable factors such as age, sex, height, experience, previous injury, and general health are equally as important to investigate[11]. A systematic review conducted in 2016 found that the biggest risk factor for developing a running injury is a history of a previous injury[11]. 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 ensure 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 analyzing 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 [13]. Instead of using the screening tools to try and predict future injury you can use them to assess a patient's 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, backbend, rotation, single-leg balance, and squat can be assessed, and then components of each movement analyzed in more detail [14].

The videos below show some examples of various movement screening tests

Blog based on the unilateral hip bridge endurance test

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 analyzing running kinematic patterns[13][15].

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: [14]

  • The Overstrider
  • The Collapser
  • The Weaver
  • The Bouncer
  • The Glut Amnesiac

Step 4 - Create a Comprehensive Plan of Care - (Treatment/ Intervention)

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 individualize 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[14] 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 center treatment around the specific aspects that address the runner's unique problems.

1. Mobility

A dynamic warm-up is an initial component of a training program. Incorporating dynamic stretches into any pre-activity warm-up is superior to static stretching although the physiology behind this is still uncertain[16]. 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[17].

Static stretching, PNF, and dynamic stretching have all been shown to positively influence the joint range of movement[18]. 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[18].

There is no “standard” mobility programme for runners and your assessment findings will guide your prescription.

2. Stability

Addressing motor control and muscle strength impairments by means of an exercise program has consistently shown to be effective in improving running economy and performance in middle and long distance runners [19].

The therapist will have identified any motor control or strength deficits during their assessment and an individual program 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 specific movement dysfunction can be found here.

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 the center of mass excursion [20][21][22][23]. There is a good carryover from a gait retraining programme with runners maintaining the changes even after 1 month follow up [21][24].

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 [25][24][23]. A 10% difference is enough to change forces experienced through the knee [25] and does not affect running efficiency [24]. 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[25]. 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: [26]

Important note: caution should be taken in changing the biomechanics of runners, particularly with high-performance athletes, if you are inexperienced in doing so[14].

The Overstrider

  • Increase cadence[22]
  • 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[22]

The Bouncer

  • Increase cadence [22]
  • Encourage softer landing

The Weaver

  • Encourage a slightly wider base of support[14]
  • Run along a straight line and make sure feet are on either side of the line

The Glut amnesiac

  • Encourage more trunk flexion whilst running (may need to strengthen first to achieve this)[14]

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 [18].

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

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