The Author

Steve Gonser DPT

Steve Gonser graduated with his Doctorate in Physical Therapy from Daemen College, instantly applying his knowledge of human movement and functional anatomy to his passion for running. Steve is a 2x Ironman, including a 10:41 finish in Lake Placid and a Sub-3 hour marathoner.

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Shin Splint to Stress Fracture: Cause & Prevention

Shin pain can be a frustrating, viscous cycle. Shin pain is not a diagnosis, but rather a vague term for where you hurt. The injury itself can be somewhat minor (shin splint) or rather major (stress fracture). Generally, the development of shin pain can be abrupt, but usually the runner is at fault. A minor shin splint improves as you run (“warms up”), but the absence of symptoms doesn’t translate to absence of damage. As you run the injury slowly worsens and eventually the tide turns. That measly “I can run through it” shin pain develops into distinguishable, distinct, dig with your fingertips type pain.

At first glance you may think that a shin injury is an impact injury. Well, yes and no. Inner shin issues (shin splints, stress reactions, and stress fractures) arise from tensile forces to the bone-not compressive. Our skeletal system craves compressive forces–the bone responds to compressive forces by building more bone, thus making it strong. On the other hand, tensile (pulling) forces are bone kryptonite. The easiest analogy is to think of bending a tree branch. As the branch bends, it’s not the compression side that breaks, but the tensile side. As our foot strikes, the ground reaction force transmits through the foot and up the chain into the spine. The ground reaction force attempts to bend bones at a repetitiously at a high velocity.

Here’s a video for our members…

shin-splint-member-video

These tensile epicenters, the lower inner shin being one localized area, are structurally supported by our muscles. The muscles pull up and prevent the analogous tree branch from bending. Lower shin injuries are not a product of a single foot strike, rather a repetitive, rapid tensile load that occurs during every foot strike. If you’re muscles are simply unable to stop the tree branch (bone) from bending, the result is irritation (shin splint), to bone inflammation (stress reaction), and eventually breaking (stress fracture).

shin, pain, stress, reaction, prevention, cause

A retrospective study found that 50% of stress fractures are found in the bottom third of the tibia.1 Causation is multifactorial. For example, in this article I discuss the link between muscle fatigue and the rate of acceleration and loading while running. In short, increasing fatigue causing quicker loading rates between body and the ground, while the acceleration of the tibia (shin) progressing forward increases. The studies outlined in the previous article are relevant when we link them to other research studies. Milner et al. found that the occurrence of stress fractures in female runners was related to greater initial loading of the lower extremity.2

It all sounds like an impact issue, right? Don’t be fooled. It’s not the landing that’s causing these injuries, but the poor control of landing. Your body weight doesn’t fluctuate when you run (outside of sweating). Body weight is constant, but loading rates can change drastically. Without strength at key areas the loading rates between your body and ground maximize. Another research study focused on female runners showed that, when compared to controls, the stress fracture group demonstrated increased hip (peak hip adduction) and knee motion (internal rotation).3

Ultimately, an unattended shin splint will progress. A slight “ache” transforms into pain that limits you from running (stress reaction) and ends with pain that is present with walking and standing (stress fracture). You’ll want to focus on strengthening key areas with runner-specific exercises. Targeting your hips, knee, and lower leg can help prolong fatigue and devastating tensile forces.

Wondering where to start with your hip strength? Start with our BaseSix Bootcamp.

12 Runner Specific Workouts Over Six Weeks

Train Movements, Not Muscles. BaseSix will help you improve strength and achieve balance through PT-designed exercises from BQ-Runner and Physical Therapist, Steve Gonser.


References

1. Monteleone, G. P., 1995. Stress fractures in the athlete.Sports Med. 26, 423–432.
2. Milner, C.E., Ferber, R., Pollard, C.D., Hamill, J., Davis, I.S., 2006b. Biomechanical factors associated with tibial stress fracture in female runners. Medicine and Science in Sports and Exercise 38, 323–328.
3. Milner, C.E., Davis, I.S., Hamill, J., 2005. Is dynamic hip and knee alignment associated with tibial stress fracture in female distance runners? Medicine and Science in Sports and Exercise 37, S346.

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The Sitting Athlete

Sitting is the new smoking. Yeah. That and fast food. If you haven’t heard, sitting is bad for you. The research has found decreased life expectancy for those sitting >3 hours a day and increased disc pressure at the lumbar spine, which can result in back pain and accelerated aging of the spine. The research is fairly clear on spine mechanics, but what about it’s effect on your ability to run? As a society we sit more than ever. We sit for breakfast, lunch, dinner, while driving, and for 8+ hours a day as a desk jockey. The sitting posture is a breeding ground for targeted tightness, particularly in the hips and thoracic spine. And although there’s no research (that I can find) proving that sitting can be a risk factor for hip flexor tightness, I’m going to run with it (pun intended).
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Overpronation, Running Injuries, and Evaluation

“Your ankles and feet overpronate… you need ‘x, y, and z.’” X, Y, and Z typically reference to a strengthening program, shoe change, or orthotic prescription. Overpronating is a term that is thrown around loosely, whether it be a clinician’s office (PT, Ortho Doc, Podiatrist), in print publication, online, or at your local shoe shop. If in fact you do overpronate, is it something that you can change?

Being classified as an overpronator is fairly subjective. There’s no criteria to classify you as a runner who overpronates. The subjectivity of the term is likely the exact reason that it’s thrown around so loosely. In truth, overpronation is dependent on your anatomy. For example, if you have 15 degrees of pronation and use all 15 you’re likely an overpronator, whereas a strong runner may only pronate 5 degrees through available range– more on this below.

over, pronation, runsmart, why, do, i
Here’s a perfect example of single-sided overpronation. Yep, you can actually overpronate on a single side. In standing both feet looked symmetrical; however, a simple running exam exposes true function under load. In fact, the excessive pronation on right foot was not evident through observation during walking, squatting, or single-legged activity. As you’ll see below, the answer to this movement error includes supporting while building strength.

As previously discussed here, pronation is completely normal. Pronation allows your foot to unlock and distribute force up the chain (leg). Pronation that fails to occur, whether it be due to an orthotic, bony structure (high arch), or motion control shoe, may actually increase ground reaction forces (impact). It should make sense, too. Blocking your foot from pronating disengages the first anatomical system for absorbing impact forces.

“Over” insinuates that you pronate too much, but who gets to determine what’s considered normal? We have values that are deemed “normal,” but varying foot structures complicate the situation. Varying degrees of high, neutral, and low arches all affect this “normal” pronation number. “Normal” pronation numbers will simply be out of reach for rigid arches, while flexible feet with surpass the numbers. To dilute the situation further, your strength, habits, and flexibility can all influence how much you pronate. It’s not uncommon for a runner with plantar fasciitis to run on the lateral or outside portion of their foot, essentially compensating to avoid a painful inner heel. In this instance, pain avoidance limits pronation. Weakness in your pronation control muscles will also cause you to drift further into your range of motion, overpronating. As we can see, overpronation is multi-factorial and typically requires some evaluation.

For the sake of keeping it simple, let’s assume you’re running pain free with no relevant past medical history. Whether you have a flat, neutral, or high arch we can say you have an available amount of range into pronation. Overpronation equates to working closer to your end range while running. A 2013 study found that injured runners use more of their available range, leaving 4.21° of buffer to end range, whereas healthy runners maintained a 7.25° buffer. 1 The study evaluated runners with anterior knee pain–note how the foot is causing problems up the leg. The ultimate cause of overpronation is a lack of strength or poor movement (toeing out). It’s more than strengthening your feet, though. Muscles that control pronation include the buttock (glutes) and inner shin. Strengthening and balancing the entire limb can stop you from falling towards end range pronation. Building strength to control pronation can take time. Enter orthotics or stability shoes. Adding external support via an insert or stability shoe can assist in controlling pronation while you’re waiting for your strength to develop. A 2007 study by Cheung & Ng found larger pronation angles in neutral footwear when compared to motion control shoes.2 Simply put, the less external support the greater the chance for over pronating. Good strength in the glutes and foot can better control pronation while running and maintaining your buffer to end range motion.

It’s not uncommon practice to support a weak runner with orthotics; however, it seems to be the answer all too often. The other end of the spectrum characterizes support shoes and orthotics as a cancer to the running community. Like most things, the answer lies somewhere in the middle. I use orthotics or shoe changes to supplement treatment. Some runners wean their feet as strength and balance improve, while others are long-term or life users. A natural progression for descending external shoe support looks like this: motion control, light stability, neutral. Each category has varying degrees of stiffness and break at the toe box. Depending on the strength and foot type you’re bringing to the table your starting part will likely be different than others. A strong foot paired with a low or neutral arch can work well with a neutral shoe. It’s really about the overlap. Overpronation is rooted with a lack of either internal (muscle) and/or external support (shoes).

Remember, overpronation is usually a product of strength, flexibility, and foot type. For most the answer is always about pairing strength and shoe selection with your foot type. A good clinician and knowledgeable shoe store rep are your best path to a good fit for your current foot status. Strength and flexibility are moving targets, while foot structure can be static.

References

1. Rodrigues P1, TenBroek T, Hamill J. Runners With Anterior Knee Pain Use a Greater Percentage of Their Available Pronation Range of Motion. J Appl Biomech. 2013 Apr;29(2):141-6.

2. Cheung, R. T. H., & Ng, G. Y. F. (2007a). A systemic review of running shoes and lower leg biomechanics: A possible link with patellofemoral pain syndrome? International SportMed Journal, 8(3), 107–116.

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2 Self Tests for Core Stability

Low back, pelvic, and hip stability are so important. I’ll relate them back to a concept of “proximal stability.” I’ve touted the benefits of core strength before–both articles can be found here and here. I’m not looking to beat a dead horse, but simply expand upon these concepts with a couple simple home tests that can help you understand what you’re bringing to the table. Loss of proximal stability can happen for various reasons: pregnancy, hormones, lifestyle (sitting), or maybe even complete neglect in your strength program (or lack there of). And although I’m going to relate this all back to postpartum moms, this article and the tests apply to all runners. Research notes measurable weakness 12 months postpartum. Again, this weakness may even last longer… the study simply ended at 12 months. Also, there’s little evidence of how multiple pregnancies fare for moms. I presume through clinical observation that the issue is only compounded both in the amount and duration of weakness.

As previously described both here and here, moms take the blunt force of losing proximal stability. Not only do expanding abdominals muscles lose strength, but hormones released during pregnancy and delivery compromise another source of stability: ligamentous support. A properly named hormone, Relaxin, is released in the late stages of pregnancy to soften the pubic symphysis and increase ligamentous laxity surrounding the pelvis. This joint laxity paired with the noted strength deficits through the abdominal wall significantly compromise any proximal postpartum stability. Before you start talking trash to relaxin try to remember that it’s necessary for delivery and safe passage of your little one.

Mothers who undergo cesarean sections (c-sections) are not immune to the destabilizing release of relaxin; however, a c-section has been found to limit the loss of pelvic floor strength postpartum when compared to that of a vaginal birth.1 The body will always assume a vaginal birth, which is why the relaxin is unavoidable. The fact that the abdominal wall is cut during a c-section may, in fact, provide increasing and long term instability at the lumbar spine (this is a presumption).

Identification is half the battle. You’ll want to investigate your overall strength and stability through the spine, hips, and pelvis. A few simple movements can give you a small glimpse into stability. These two movements are always included in a patient exam, whether it’s a man or woman. Although there are far more extensive exam components, these two simple tests can give you a quick glimpse and better understanding of your core, hip, and pelvis stability.

The goal is to apply unilateral force through the spine and pelvis. The momvement requires your muscles to stabilize and prevent movement. Since ligamentous laxity is not thought to resolve to preexisting levels, stability of your spine, pelvis, and hips falls to your muscles. Before attempting these movements there’s an assumption that you’re capable of performing each properly for a full minute. Unable? You know it’s time to start improving proximal stability.

Movement One: Single Leg Bridge

core, stability, test, running
Laying flat on your back, engage your abdominals, drive through your heels, and lift your butt. There should be no movement of your spine. After sustaining the posture for 10 seconds, lift one heel from the table (only an inch). Doing so effectively engages the spine and weight bearing hip. The pivot point that occurs around the weight bearing hip places a single sided stress on hour hip and spine. Weakness and decreased stability will be noticeable to an onlooker, you may or may not be able to feel weakness. You’re looking to see/feel if you can hover one leg without allowing your butt to drop or opposite hip to dip. Hold for 10 seconds. Typically, we’ll see a small weight shift that is instantaneous with a hip drop on the leg being lifted.

Movement Two: Single Leg Plank

core, stability, test, running
Similar concept as above but first be sure you’re performing your plank right. Here is an article that outlines proper planking technique. You’re looking to ensure that you, as the plankee, don’t allow your low back to fall downward while maintaining a pelvis that is parallel to the ground. Tighten through your core muscles and plank. After 10 seconds lift and hover one foot by two inches–look for weakness. Weakness will be visualized through a pelvis that fails to remain parallel to the ground. Repeat on the opposite side.

Luckily, we can all run with underlying weakness; however, eventually the tipping point is reached–you’ll need to pay the piper. Restoring core strength and stability will be a necessity to overcome recurring injury. Single sided weakness is not uncommon, either. You may find that hovering one foot versus the other yields different results. No matter the response the answer is the same. Begin improving core strength and stability.

We are roughly two weeks from launching our answer to this question: a complete video series of progressive strengthening for mom. The aim is to restore core strength, while providing a specific plan that reintroduces running in a manner that decreases the chance for injury. But first, we need you and your feedback.

References

Y.B. Baytur, A. Deveci, Y. Uyar, H.T. Ozcakir, S. Kizilkaya, H. Caglar, Mode of delivery and pelvic floor muscle strength and sexual function after childbirth, International Journal of Gynecology & Obstetrics, Volume 88, Issue 3, March 2005, Pages 276-280.

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Safe Return to Running Postpartum

“Do you have any kids?” A question I frequently ask my female patients during my past medical history. I’m not even looking for recently, either. As we’ll see in the research below, the effects of bearing a child are measurable up to 12 months (and that’s only because they stopped the study). It’s an often overlooked question by exercise professional that provides great anatomical insight. It goes without saying (although I’ll say it now anyway) that the female body takes a beating while carrying a child from conception to birth. Unfortunately, we can add postpartum months (or even years) to the already completed nine months. The combination of a growing baby and fluctuating hormones, particularly those at birth, can extremely compromise proximal stability.

With a six month incidence rate of 27% and nine month prevalence of 49%, back pain is overwhelmingly common in expecting mothers.1 A growing baby causes observable changes in posture and muscle length, particularly of the abdominals. The constant stretch held throughout pregnancy can thin, weaken, and even tear your rectus abdominis (traditionally thought of as the “six pack”). Such a constant stretch, one so persistent and strong that it can actually tear the muscle, greatly affects strength. Research conducted in 2011 found that tears in the abdominal wall, known as diastasis recti, as well as abdominal muscle function improved since birth, but had not returned to normal values when measured six months postpartum.2 Another study that was conducted for the first year postpartum found similar results. The abdominal wall was healing, but not healed. Subjects had a thinner, wider rectus abdominis, while the diastasis recti continued to shrink.3

postpartum, runninng, strenght, mom

Looking at the above image it’s fairly easy to see the changes in muscle length. Luckily our muscles are fairly elastic and allow for such a stretch; however, the prolonged lengthening of the musculature compromises both strength and stability well beyond delivery.

The weakening and thinning of the abdominal beyond delivery can certainly create some bumps in the road for running moms looking to get back on the horse. As we’ve seen in previous articles, diminished core strength can cause an array of lower body injury (read our previous article on core strength here). The key here is to be patient and to begin a core and pelvic floor strengthening program when deemed safe. Your ability to begin a core strength program will likely depend on mode of delivery. The increased recovery time associated with a caesarian section will have you pumping your brakes for a little bit longer.

I’m ready… where to start?

I often recommend spending time will more gentle, easier modes of aerobic exercise. Aerobic exercise will be fine, but you’ll want to limit impact forces. I know. You’re chomping at the bit to hit the roads again but be patient. Remember, you’re proximal stability (hips and spine) is lost. Running too early will likely leave you sidelined for a few weeks. The first four weeks of exercise (note: this is the first four weeks when you’re ready to begin) should include walking, cycling, and progressive strength training. I highly recommend nixing running as your “get my pre-baby body back ASAP” choice of exercise. Emphasis for your progressive strength program should be at the hips, pelvic floor, and abdominals. Once you begin your return to the roads you’ll want to spend a minimum of four weeks of easy running, working your way back to typical mileage. Tack on another four weeks of occasional higher intensity runs and you’ll likely be ready to begin racing. Yes, that’s weeks of strength training, a minimum of four weeks of ‘getting back into the swing of things’ running, and another four weeks of higher intensity running before you’ll begin planning your race calendar.

Again, this isn’t only for the mothers who recently carried a child. The results are likely measured beyond 12 months, but it happens to be the last data point for the researchers above. I’m sure most moms will attest that the effects certainly span longer than a year. So whether you’re a new mom, adding to your family, or beyond adding, improving spine stability is a must… not only for running, but for life.

References:

1. Ostgaard H, Andersson G, Karlsson K. Prevalence of Back Pain in Pregnancy. Spine. 1991 May;16(5):549-52.
2. Coldron Y, Stokes M, Newham D, Cook K. Postpartum characteristics of rectus abdominis on ultrasound imaging. Man Ther. 2008 May;13(2):112-21.
3. Lih-Jiun Liaw, Miao-Ju Hsu, Chien-Fen Liao, Mei-Fang Liu, Ar-Tyan Hsu. J Orthop Sports Phys Ther. 2011;41(6):435-443

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Movement Training After Adding Strength

As clinicians, we often explain injuries in the form of strength or flexibility. We’ll drill you on exercises that have been proven to engage specific muscles or stretches that make you feel your tightness. Generally, these issues get addressed with onset of the direct feedback that something has gone astray–PAIN. Although pain appears to be fairly black and white (it either hurts or doesn’t), the road to pain often starts weeks, months, or even years prior. Strength deficits and hampered range of motion often go undetected for months due to our inept ability to compensate. As I state in prior articles, our body is amazing. It has systems for checks and balances, a way to compensate for developing issues. Good thing, too. Relying strictly on one area for function would be disastrous for living. A failing ankle without a knee, hip, or trunk to compensate would leave you bed-ridden and unable to walk. Again, completely unbeknownst to the person, your brain will make deliberate changes to your movement in response in an attempt to keep you functioning. These compensations become hardwired into your movement. The movements are now automatic, learned habits that fire subconsciously.

What does this mean for you? Not only must you restore strength, but you’ll have to spend time re-learning your movement. We all know about the importance of strength training, but how about movement training? You need to feel and own your movement. The difference between strength, muscle activation, and movement is often overlooked. Muscles can be both strong and weak at the same time. Yeah. I said it. A strong muscle can generate force, but can it play nice with those surrounding it? Will your new found strength even be used if your brain has trained the movement to get by without it? It’s a tough question to answer through research, but we know more about movement and the neuromuscular system than ever before. In practice, I can abolish knee pain during a squat by biasing the glutes to activate. The same can be said for those with back pain. How is it I can toggle from a runner from painful to non-painful with a few simple cues? The answer lies in your bodies inept ability to run on autopilot. Again, your brain has trained the body to function with compensation. Simply adding strength or range to the mix doesn’t necessarily equate to improved movement.

It’s fairly crazy how one person can look so strong or weak on exam, but then when we ask them to function in sport and their movement fails to reflect what we’ll see on the table. If you train your body for the strength test of course you’ll test strong (hello clamshell and leg raise exercises), but more often than not you’ll still function poorly with movement.

It’s fairly crazy how one person can look so strong or weak on exam, but then when we ask them to function in sport and their movement fails to reflect what we’ll see on the table.

Since these movements are perceived as “normal,” self assessment is almost impossible here. You’ll need a trained eye for not only identification, but to instruct you on movement correction. From clinical experience, there are a few factors that affect your ability to correct your movement. First, the duration of time spent compensating can directly influence your ability to not only feel, but fix the movement. Simply put, the longer you’ve been compensating the more ingrained the habit and the harder to break. Second and more influential factor is your body awareness and coordination. Those who are better at coordinating movement and being in tune with the spatial relation of their body parts will generally have an easier time fixing movement.

Luckily we can continue to run with poor movement–our anatomy allows it. Fixing movement is really reserved for a few groups. Those with glaring form issues: flailing feet, outward/inward pointed toes, and excessive hip drop. The second group is for those who have fought persistent on/off injury for months (or years) on end. It’s also reserved for those who are running to put food on their plate. A level where everyone is elite and first and second place are separated by fractions of a second.

Below is an example of a young runner who you would expect to perform weak while running based on exam, but shocks me when she overshoots her strength testing.

The importance thing is to fix the strength and flexibility issues first. Afterall, it’s tough to change your movements if you don’t have a prerequisite strength to stop the compensation. So go find out how you’re compensating and start rewiring your nervous system to break bad habits. Learn and feel how your body moves. Only then can reach your full potential while avoiding persistent injury.

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3 Bad Stretches for Runners

We know more than ever about function and the intricacies of how our body responds to positioning, sport, and load. Yet, the general running population is continually spoon fed the same stretches from 1980. I’m not sure why, really. Countless research articles have shown the detriments of bending movements on our spine (including sitting), but the majority of runners still bend from the waist to “stretch” their hamstrings and IT bands. We know the importance of movement specificity for not only sport, but life. Yet we continually move in ways that neither look nor feel like running. Stretch your calf? Sure. Let’s wedge your foot on the wall and smell some paint. Below I highlight three stretches that are often used, but shouldn’t be. Stretches that can be fairly harmless (calf stretch below) or part of a bigger picture causing long term injury (see ITB and Hamstrings Stretch below).

#1 Hated Stretch – Bending Hamstrings

bad, stretches, for, runners, runsmart
What? You want to stretch your hamstrings? Great. Then stretch them, but leave your back out of it. Fact is, most low backs are too mobile. Our forward flexed lifestyle promotes sitting and bending more than ever. Said lifestyle fosters tightness in and around your hips and pelvis and requires your low back to compensate and increase its flexibility. What’s designed to be a stable environment slowly transforms into a sloppy mess of excessive movement and accelerated wear and tear.


Instead, keep your spine straight and flex from the hip. Not only will you remove damaging forces from your spine, but you’ll also feel the stretch sooner. The trick here is to flex from the hip and maintain the natural concavity of your lumbar spine. Be careful to not pull up on the toes as it may transition your stretch from your hamstrings to the sciatic nerve.

#2 Hated Stretch – IT Band

bad, stretches, for, runners
Who knows where this came from? What a crap shoot. This common IT Band stretch not only increases the load to your lumbar spine, but it fails to target the thick, fibrous band altogether. With the average person placing 2-4,000 bending movements on their spine every day1 and placing up to 150% increased pressure through their lumbar discs while bending2, do we really need more bending? The answer is no. Plus, the IT Band isn’t an overly elastic tissue, which means it doesn’t stretch well. Performing stretches and soft tissue work to the muscles that attach to IT Band (Glute Max, Tensor Fascia Lata) and those who are nearby (lateral quadriceps) are best. Go grab your foam roll and get rolling.

#3 Hated Stretch – Calf Stretch

bad, stretches, for, runners


Specificity is the rule–there is no exception. Your exercises MUST mimic function. It’s the same reason why a strength training program for an offensive linemen is different than that of runner. Two different sports–two different athletes. Treating your body with exercises and stretches that mimic the running motion is so important. When we run, our lower leg muscles, namely the gastrocnemius and soleus (calf muscles), accept load with our foot fixed to the ground. With our foot fixed the shin glides forward, loading mainly our soleus muscle. Why then are so many people wedging their foot into the wall and smelling paint? This simple, overused stretch is a runner favorite for tight calfs. Sure it stretches, but aside from smelling the wall, you’re moving your foot on the shin–precisely the opposite that happens when we run. Again, simple changes can make a big difference in the longevity and consistency of your running career.

References

1. McGill, Stuart M., et al. “Coordination of muscle activity to assure stability of the lumbar spine.” Journal of Electromyography and Kinesiology 13.4 (2003): 353-359.
2. Nachemson, Alf, and G. O. S. T. A. Elfstrom. “Intravital dynamic pressure measurements in lumbar discs.” Scand J Rehabil Med 2.suppl 1 (1970): 1-40.

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W-Sit Your Way to Lifelong Running Injuries

As a clinician I often take what I’ve learned as common knowledge. I look at the habits and reasoning behind patient actions and think, ‘why on earth would you do that?’ I simply forget that we all haven’t sat through an applied anatomy and movement lectures, labs, and continuing education.

Truth be told, some athletes are simply more durable than others. It might frighten you to hear that some factors associated with injury prevention are out of your control. Genetic durability, anatomical make up, and past injuries all influence our ability to function. We all have that friend that can pound on themselves and seemingly take it unscathed. They remained healthy… for now. Those seemingly indestructible runners are an outlier for the time being; however, take solace in knowing they’ll eventually be another data point in growing statistics displaying high injury rates amongst runners. Flip the script and you’ll find a friend who appears to always be hurt. While I’m a firm believer that consistent injuries are more a byproduct of how you treat your body (training, strength, etc.), there are some who can’t stay out of harm’s way. More horrifying, the cause of recurring injuries could be a result from the way you sat decades earlier.

As we grow and develop our body conforms to external stressors. To some extent we can dictate our anatomy. Even the way you sit or sat 20+ years ago can influence how you move today. A common sitting technique, called ‘W Sitting’, is common in pre-teen and teenagers. Although it’s usually females, males do it too. It’s fairly easy to pick out as a parent or coach. The offender will be sitting in what resembles a ‘W’ (clever, huh?). Both ankles will be positioned on the outside of the hips with their butt on the ground. Not only is W-sitting terrible on the knees, but can also create permanent deformation and hypermobility in the hips.

W-Sitting causes excessive inward (internal) rotation at the hips. With consistency, W-sitting will eventually cause lifelong changes in tissue length. The excess range will essentially remove a natural barricade. Hang with me. As we run, we load into internal rotation, which is controlled by your glutes. The worst and probable scenario is that your hips are weak. Weak hips will cause you to spin excessively inward into internal rotation. For those with no junk in their trunk, the hips will eventually reach an anatomical block, the same way your elbow can only extend so far. Individuals who W-sit essentially remove this normal restriction at end range. They literally just keep spinning, falling off a hypothetical cliff. They have no end to their rope. No buttress to stop them if their hips are weak (which they usually are).

Identifying W-Sitters Decades Later

w, sitting, running, injuries
Through a simple exam you can usually identify the W-sitters fairly easy. A simple test on measuring hip internal rotation reveals excessive range measuring well over 70 degrees. Normally, our hips allow for 45 degrees of rotation. Once a W-sitter always an excessive rotator. You’re essentially stuck with your anatomy at this point. From here, you’re going to require maximum core and hip strength. You essentially have no end to your rope and will require your muscles to control through the range of motion.

The important piece is to discourage it altogether. Coaches, parents, friends, whoever… don’t let your athletes, kin, or friends W-sit. For those of you who already bit the bullet–the damage is done (or continues to worsen). First things first, stop. Next, you’ll want to maximize hip and core strength. Your muscles will have greater responsibility for controlling the forces imparted by running. W-sitting and the associated hypermobility can be the route cause to reoccurring injury. For some, it will have you running on eggshells, constantly fighting off minor to major injury woes throughout your career. One thing is for certain, though: you will need a greater attention to improving your hip and core strength.

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Improving Movement & Fixing Compensations

Balance is important. Not only for running, but life. It’s surprising how many athletes are unable to balance on one foot. Completing this seemingly rudimentary task can be shockingly difficult. Harder yet is completing the task without compensation. Compensations are often subconscious. The more we compensate the more our body perceives the compensation as ‘normal’ movement, further building the movement subconsciously and making it more difficult to correct–or notice for that matter.

If you compensate with lower functioning tasks (balancing on one foot), you can only imagine how this carries over into more strenuous and higher functioning activities (running). Worse yet, fatigue and pain can cause our compensations to exaggerate. Fatigue during a hard workout or race will exaggerate poor movement. Pain associated with injury or exhaustive works can also exaggerate compensations. Without identifying and implementing corrective exercises it’s nearly impossible to correct a compensation. Remember: most athletes are unaware of their compensations. Simply throwing more stretches and strength workouts into the mix many not be the answer, either. Although most compensations are built off a foundation of weakness and/or restrictions in mobility, fixing underlying cause may not improve your compensations. You’ve learned to move this way, remember. You’ll need to unlearn it.

Getting Back to Basics

Back to the basic movement of standing on one foot. This simple task can give you a glimpse into your movement. You won’t need a pair of trained eyes on you, either. Stand facing away from a friend, spouse, or child. With no other direction than standing on one foot, balance for 10 seconds while a video or image is captured. Then it’s analysis time:

compensations, hip, weakness, runsmart
The above image displays a common compensation for hip weakness: lateral lean. The left image is unsupported and was performed with no verbal cues. A lateral lean shifts your center of mass closer to the hip joint, effectively decreasing the lever arm of the lateral hip muscles. Decreasing the lever arm reduces the force required from the pelvis stabilizers and is a common compensation for weakness. This movement happens during gait and will eventually become deemed ‘normal’ movement–a hard habit to break.

Carry Over into Running

You shouldn’t be shocked to hear that balancing one foot is far lower functioning than running. The compensations highlighted above carry over into running quite well. After all, the run cycle includes a period of single leg stance with every step. Usually the cause of the above weight shift is weakness in the hip and leg. The shift compensates for the weakness and allows your body to stay balanced over the supporting foot. Eventually, the shift becomes ingrained into your movement and the neuromuscular system perceives it as ‘normal’. Once the strength has returned to the supporting leg the movement needs to be fixed.

Fixing Movement

Gaining strength is far easier than breaking poor movement patterns. Fixing a movement error, particularly one that has been used for years, is fairly difficult and takes mental fortitude. You’ll need frequent if not constant focus and conscious awareness. Fading to auto-pilot is a recipe to run with compensations–literally. The brain will tap into stored, learned movements and hit the repeat button. To fix movement errors repetition and focus are a must. Start easy. Practice feeling your movement with the above test (balancing on one foot) a few times a day. Try not deviate or lean to one side. You should also refrain from allowing your pelvis to drop. Next, carry it over to walking and finally running.

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First Toe (MTP) Extension and Running Mechanics

Would you ever think something as miniscule as big toe mobility could plague your running career? Well, start answering yes. All of our joints are part of a bigger picture of movement and function. When we lose motion, balance, or strength our body compensates. Compensations are seamless, automatic, and subconscious. They are perceived as ‘normal.’ Your body has one goal: task completion; however, task completion doesn’t correlate to efficient and correct movement. If you want to stand from a chair you can stand up driving from your hips or through your knees. Both get you to standing (task completion), but each loads your body differently. A good chunk of the population believes that the way they complete a task is most efficient, because, well, that’s the way your body decided to do it. While I’m not looking to start an argument here, I can tell you you’re wrong. Ok, maybe I am looking to start an argument.
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The first toe, or big toe, but plays a crucial role in balance and locomotion. As we push off our big toe extends. The extension draws our plantar fascia taut, effectively stabilizing the foot through what’s termed ‘the windlass mechanism.’ [See Image to Right] The benefits of a stable foot at push off are fairly obvious. Stability at push off gives you a rigid lever in which to generate large amounts of force. If our big toe lacks extension, not only will our foot lack the stability needed at every push off, but something up the chain (i.e. the foot, knee, or hips) will compensate for this lacking flexibility. Here are a few compensations that result from lacking first toe extension:

Compensations at the Foot: Excessive Supination

Push off occurs through the first and second toe, but doing so requires extension. If the first toe can’t extend then push off will drift laterally to the second, third, and even fourth toes. The outside toes are not built for stability, but more adaptability when walking on uneven surfaces. As you drift away from your first toe, each metatarsal becomes slightly longer with less girth. They’re twigs to the first toe’s trunk. Push off laterally is marked with excessive supination (turned in heel) and instability. Of course, that stability will likely come from somewhere (lower leg, knee, hip, or spine). The resulting instability at the foot could cause sheering between metatarsals leading to neuromas and stress fractures at the second and third metatarsals. Plantar fasciitis has also been thought to be caused through lacking motion at the first toe; however, research has not found a correlation (yet).

Compensation at the Knee: Increased Knee Flexion

It would be simple if your knee functioned separate from your foot, but it doesn’t. First toe extension allows for your foot to supinate (heel turns in), which in turn allows your knee to externally rotate and achieve full extension. If the foot pushes off laterally at toes 2-4 the knee could fail to lock at the end stage of push off. Doing so places strain through the knee while dampening any power in your stride. Double buzz kill. Not only are you more likely to experience knee pain, but you will be running slower in the process.

Compensation at the Hip: Decreased Hip Extension

Working our way up the chain we begin to see how something as distal as the big toe can cause problems proximally at the hip. Without extension at our big toe our ability to extend our hip is adversely affected. Not only does our hip not extend if our knee doesn’t straighten (further linking entire body motion), but the shift towards the lateral toes can cause a piston-like motion at the foot that causes the hip to rotate laterally. At a time when you’re looking for strength and stability, your body responds with compensations that breed instability and less power.

How to check motion

Checking motion is fairly easy and can even turn into an effective stretch. Normal range of motion into extension measures 70 degrees but may exceed this number while running. Drop yourself into a half kneel position and flex your foot. Attempt to put your first toe flat on the ground. If you feel anything it will likely be in one of three places: your arch, heel, or joint. Feeling any tension in the arch or heel is likely due to tightness in the plantar fascia. Go ahead and stretch it. For those feeling it within the joint you’re likely suffering from hallux rigidus. No, that’s not the name of an ancient Greek warrior, but a condition often caused by osteoarthritis in the joint. A static stretch is likely to yield minimal results. An arthritic first toe may respond better to joint mobilization or external support. A more rigid shoe may help protect the toe, while a rocker-bottom can even help with push off.
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This is a real life butterfly effect. Something as seemingly insignificant as your big toe can have major effects elsewhere. Remember, it’s common practice (or should be) to assess the entire movement chain when assessing an injury. Hip pain, knee pain, and foot pain could be stemming from your big toe. If you feel tight or restricted, try stretching. As always, seeking the help of a physical therapist or other clinician who has a higher understanding of movement is always advised.

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