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Sunday, January 8, 2012

Analyzing the run

  So, about a month ago, after long hoping to get a chance to mix work and pleasure, I had the chance to go to a running injury/form course in Chicago.  As I recently got around to describing, I've suffered from my fair share of overuse injuries common and strange in the past, and I've tried every pair of shoes, orthotics, stretching, and strengthening exercise imaginable.  I've heard every theory from tight hamstrings, to tight calves, to tight hip flexors, and finally to inactive glutes, which, coincidentally, has made the largest difference to work on.  But I digress.  I've always enjoyed working with runners in the clinic (having a patient complete a marathon is something tangible to me, a sense of satisfaction I can relate to and be glad to take a part in), but even though I've done my reading when I can and had my own experiences, I wanted to be able to offer something more.  So, off to Chicago it was, where I would finally learn about the nuances of video gait analysis.  The course was awesome, and since then, I've had the chance to start some taping and applying what I learned (nerd alert).  Really, though, I'm enjoying taking something as ingrained as someone's running style, slowing it down, dissecting it, trying to figure out what's going wrong where, how it matches with clinical presentation and static exam components, and figuring out where to go from there.  Without further ado, then, because he always complains that I "never want to help him" (and because I can't legally broadcast pictures of actual patients), I'll highlight some of the stuff I look for using Dave's video.  I should add that I've been dabbling around with different free trial version of software for analysis, so if some of my little lines look sort of amateur-ish, they kind of are, given my technology impairments.

Exhibit A: Dave's left leg.  Some background here is that Dave has a history of some on and off left knee patellofemoral pain.  He was seen by one of my colleagues for it, who helped him out a good deal.
The line connects Dave's hip joint center to ankle joint center.  Ideally, the knee joint center should also fall along this line.  Dave's falls slightly to the inside of it, which is a pretty common finding in runners with knee joint pain (one name for it is dynamic valgus).  It's fairly mild in him, though.  There's some left hip drop, although again not too bad.  Interestingly, his left shoulder is also lower-generally, the spine would sidebend opposite the hip drop to keep the shoulders/head more level.  I never said Dave was normal, though.  My coworker who had worked with Dave was somewhat surprised to see any dynamic valgus and hip drop on this side, even mild, as this can be caused by poor hip abduction strength, something she was unable to appreciate on static exam alone.  A good number of studies have shown decreased hip abduction and external rotation strength, as well as this dynamic valgus with different tasks (usually step-down tasks) in patients with patellofemoral (front of the knee) pain.  Here's where it gets fuzzy, though-is strengthening those muscles alone enough to help treat?  Is the weakness the cause or effect of injury?  Right now, while strengthening likely helps, adding in an awareness/neuromuscular control component is thought to be just as important.  Just providing real-time feedback (using fancy computer stuff that most normal clinics wouldn't actually have) to get runners to avoid this valgus has been shown to help.  More practically, part of Dave's theoretical treatment program would include some sort of step-downs in which he focused on preventing his knee from collapsing to the inside of his toes, as well as an awareness of it while running.

Exhibit B: Dave's right leg
Pretty good.  The center of his knee falls closer to that line, and his pelvis (and shoulders) are more level.

Exhibit C: Initial contact from behind
Dave lands slightly to the outside of his heel, in slight supination.  This is fairly normal-"normal" is considered to be landing in slight supination, pronating a bit in midstance as the foot flattens out a bit to help attenuate shock, and then resupinating prior to toe-off in order to lock the foot into a more stable position and provide a more stable base for push-off, usually over the second toe or so.

Exhibit D: Midstance
Dave does some interesting stuff here that I'll attempt to postulate about.  During midstance, the average runner will show a little bit of rearfoot eversion (heel turns slightly out).  Dave's probably about normal with that.  Also, some "toe out" is normally seen-usually the lateral two toes can be seen.  It's hard to tell with the shoes on, but it does look like Dave's a little more toed out than "normal".  But, this has to be taken with a grain of salt due to the camera angle-the "too many toes sign" should be determined by looking directly into the back of the heel.  Dave's entire foot seems like it's rotated a bit, i.e. I'd have to move a little bit to the left to get the right angle on him.  More likely, part of this rotation is occurring at his hip/knee, rather than from excessive collapse of the forefoot on the rearfoot.  It helps that I know that Dave has pretty high-arched, rigid feet.  So, my thought, given that he always complains about pain in some of the hip external rotators and his lateral hamstrings after he runs, is that he's overfiring those muscles.  The end result is that his leg rotates out in an attempt to bring the inside of his foot down closer to the ground.  The dilemma is what to do about this.  If I was a nice wife, I'd maybe try mobilizing his foot and making it more flexible.  Or, because I'm me, I'll make sure he's wearing a cushioned shoe with some give to it (he is), and tell him to keep working at strengthening, foam rolling, and stretching his glutes/smaller butt muscles (and to suck it up, I'm really nice sometimes.  But Dave's whiny sometimes, too).

Exhibit E: The front view
   The front view helps to confirm the back view.  Again, the foot/leg rotation are evident here.  The valgus (collapse in) at the knee doesn't look too bad from this angle.  I just tried to rotate my leg out while letting my knee collapse in a bit-quite a recipe for knee pain!

Exhibit F: Initial contact

A few weeks prior to this, I had filmed Dave for a work inservice.  At that time, he was running with a cadence of about 80-85 strides/min, and had been overstriding a bit, landing with a fairly extended knee pretty far in front of his center of mass.  Since then, he'd been working on increasing his cadence to about 90-95 strides/min in these videos.  This has helped him land with a little more knee flexion and the foot closer to his center of mass, which helps decrease the force transmitted through his shin and up to his knee.  In this picture, Dave's best classified as a rearfoot striker-he's not coming down excessively hard on his heel, but is still landing on the back of his foot.  Nothing wrong with this, though; a worse braking force would occur if his heel was landing further in front of him, with his knee in greater extension.  The angle between his foot and the ground looks fine, as well- too great of an angle can stress the anterior shin muscles (from pulling the foot up), and also possibly cause some Achilles pain (puts it on greater stretch).  What can also be seen from this view when the video is running is something consistent with his left hamstring pain- his left heel doesn't rise up quite as far as the right during swing phase.  This is more likely to be a result of the pain (he's not generating as much force with the muscle) than the cause of it.

Exhibit G (last one, finally!): Me
Just figured I should throw on a picture of myself, too.  After all, I have had every common running injury in the books.  My left arm is wonky.  If this picture was taken from the side, my excessive lumbar lordosis (low back extension) would be apparently.  My static foot posture, which is pretty highly pronated, vs the foot posture seen at midstance here (slightly everted and pronated, but nowhere near where I am standing) provides a perfect example of why matching someone to shoe type based upon static foot posture isn't always the best idea.  The level pelvis seen here took a spring and summer of pounding out hip exercises day in and day out after hip pain became a bit sinister in early-April.  Watching myself, it becomes pretty obvious that there's no one form flaw that could have contributed to my injuries, and it's likely that I've changed the way I've run over time, as well.

Well, I'm going to wrap it up with that!  I could continue on and analyze more, as this stuff is quite interesting to me.  As Dave demonstrates, it's not always about finding one major flaw, but rather analyzing the nuances and seeing how they play into the larger clinical picture, which includes injury history and static exam findings.  For now, though, I'll enjoy the runners that are sent my way; the more I play around with this, the more I continue to learn, and hopefully I can sort of begin to shape my career in the way I had hoped to when I'd decided upon PT school six years ago.  Rochester runners, feel free to come on by!    




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