Rehabilitation of Running Biomechanics

Introduction

Management of running injuries can be a difficult process. 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 just the source of the symptoms but the primary problems as well.

Rehabilitation of Running Injuries

To fully rehabilitate any sports injury requires a holistic approach. 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 coordination
• Functional Rehabilitation
• Use of Orthotics
• Psychology of Injury

Running Biomechanics

Inefficient running biomechanics play an important role in the development of running injuries (1). 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. (1,4).

Assessment of running biomechanics with 2D or 3D video on a treadmill has shown to be an accurate way of analysing running style (7).

Developing a Plan of care to Address Running Biomechanics

Step 1 - Understanding Training and Injury History- (Subjective Exam)

A good initial interview with a patient is extremely important. A thorough history will allow you to fully understand the entire picture and exclude any serious pathology.

There are many risk factors to investigate when it comes to running injuries. Modifiable factors such as running distance, frequency, pace and intervals, diet, hormonal problems or changes, use of orthotics, running surfaces, warm-up, stretching and physiological aspects should be questioned (4). Non-modifiable factors such as age, sex, height, experience, previous injury and general health are equally as important to investigate (4). A systematic review conducted in 2016 found that out of all these factors the biggest risk factor for developing a running injury is a history of a previous injury (4). It is thought that the reason for this is poor rehabilitation of a previous injury possibly results in biomechanical faults that then contribute to further injury.

Asking about the runners short term and long term goals is essential to ensure 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 analysing 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 (5).

Performing a movement screen in a symptomatic runner, before watching them run, allows you to systematically examine them to determine the exact faults in mobility or motor control that are contributing to their symptoms. Basic movements such as toe touch, back bend, rotation, single leg balance and squat can be assessed and then components of each movement analysed in more detail (Course notes for video 2).

ACE Running Movement Screen picture????? https://www.physiospot.com/opinion/the-building-blocks-of-running-posture/

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. Biomechanical assessment of running using a treadmill and 2-D video analysis has shown to be a reliable means of analysing running kinematic patterns (5,6).

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 are as follows (23)

• 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 full history of a runner, a comprehensive physical examination to determine all their mobility and motor control deficits as well as a running gait analysis you should 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 individualise 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 (23) they propose a 5-part treatment plan that addresses the following aspects: Mobility, Stability, Form Drills, Gair Retraining and Flexibility. The focus on each area will differ in each runner depending on what you find on assessment. Within each area, you would focus on the specific aspects individualised for the runner's unique problems.

1. Mobility

A dynamic warm-up is an initial component of a training programme. It has been shown that incorporating dynamic stretches into any pre-activity warm-up is superior to static stretching (8) although the physiology behind this is still uncertain. Static stretching, PNF and dynamic stretching have all been shown to positively influence joint range of movement. (11) Static stretching and PNF are recommended either well before the commencement of exercise or at the end of the activity and dynamic stretching as part of a warm-up (11). 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(9).

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 programme has consistently shown to be effective in improving running economy and performance in middle and long distance runners (10).

The therapist will have identified any motor control or strength deficits during their assessment and an individual programme addressing the runners specific needs can be developed.

3. Form Drills

Using form drills when rehabilitating a runner has been thought 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 various running drills can be seen in the following video

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 knee and ankle, centre of mass excursion to name a few (16, 12,14, 18). It has also been shown that there is good carryover from a gait retraining programme with runners maintaining the changes made even after 1 month follow up (12, 17). However, caution should be taken in changing the biomechanics of runners, particularly high-performance athletes, if you are inexperienced in doing so.

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 (14,15,16,17,18,20,21,22). A 10% difference is enough to change forces experienced through the knee (20, 16) and does not affect running efficiency (17). Increasing step rate while maintaining a constant speed has been shown to reduce step length, reduce vertical oscillation, reduce ground reaction forces, reduce impact shock as well as reduces the energy absorbed at the hip, knee and ankle. (16) 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.

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. However, in a post-workout scenario, you could incorporate a more static stretching or PNF approach (11).