Video Gait Analysis

I spent today learning all about how to use the Dartfish video gait analysis system.  Fascinating stuff and will be of great value to my patients.  In the process I did of course have my gait analysed, as well as my single leg squat assessed.  Confirmation of my weak left leg!  But it was really interesting to see how the weakness affected my running and how this would translate into pain and injury because of repetitive excessive or uncontrolled movement at my ankle and knee.

It isn't possible to stress the importance of strength and conditioning work for anyone who wants to undertake physical activity.  Unfortunately, the ability to run, cycle, jump, swim doesn't just come naturally....possibly we detrain at some stage of our lives (maybe some lazy teenage years), possibly we get injured and lose strength and control or possibly we have always been lazy and never developed the strength in the first place.  We don't live in an active world anymore.  We don't have to chase our food, we sit on chairs, we drive cars...so much time spent not moving, so much time to gradually become less well adapted to moving fast, to carrying loads etc... 

So it isn't bizarre that the human body becomes overloaded when we decide we do want to start/increase training.  It takes time to build up the right muscle strength, body awareness, neural connections, bone density, tendon strength as well as cardiovascular fitness.  And this is the time for overload injury when we get too enthusiastic!

So strength and conditioning is critical.  This should encompass upper and lower body work as well as core strength.  And movements must be correct.  Wrong technique perpetuates undesirable movement patterns.  It's easy to bash out a set of exercises - but do them wrong and you are just maintaining the status quo - e.g. using hip flexors/ITB/paraspinals instead of the glutes when performing clams - where you are trying to activate and strengthen glute med.

So I'm now officially an 'accredited Dartfish video gait analyst'.  Not just another stick to beat the patients with who don't do their exercises....hopefully a means to help the patients see how they move and how they can change to move better and in the process resolve their pain and injuries.

To have a look at an example go of what Dartfish looks like go to:
http://www.dartfish.com/data/mediabooks/108/PerformanceAnalysis.html

ITB syndrome. A symptom.

The first reply to my suggestion for topics was for Iliotibial band syndrome and this is another good example, similar to plantar fasciitis, where the pain is not where the problem is.

To understand the problem you have to understand how knee stability works.  Essentially, to maintain good knee control, the body uses the primary knee stabilisers which include the vastus medialis oblique (VMO - part of your quads muscle found above the knee on the inside of your leg) and the gluteus medius muscle which is found in your 'gluteal region' (bum) on the side of the body.  These muscles work, with the other muscles of the pelvis/buttocks/thigh, to control the way that the knee moves as load is accepted onto the leg.

If this control system fails, then other structures around the knee take the load and these can be called the secondary stabilisers and include the medial hamstrings (semimembranosus, gracilis and semitendinosus) which insert below the knee joint on the inside of the leg onto the tibia (shin bone) and the iliotibial band which starts at the ilium (part of the pelvis), runs down the outside of the thigh and inserts into the tibia on the outside of the leg (but also feathers into the outside of the knee joint and the kneecap joint).

The reason that the primary control system might fail could be due to lack of strength and control through disuse (i.e. you never had the control) or injury (you had it, then you lost it).  In particular, if you develop an effusion of the knee (fluid in the knee joint) perhaps because you bash the knee on a rock or similar, then the VMO will often switch off. 

So the primary control system isn't working.  You keep loading the knee.  The secondary stabilisers take over - but they are not designed to work alone and they tighten up and become overloaded - ITB pain. 

The treatment for ITB syndrome includes stretching off the ITB and TFL (tensor fascia lata - muscle that feathers into the ITB at the pelvis) but you will never be rid of ITB pain until you sort out the stability issues around the knee. 

You can test your knee and hip strength and control by attempting a single leg squat in front of a mirror (no hanging on to anything).  See what happens to your knee.  Does it collapse in as you approach more than 30 to 45 degrees knee bend?  If so, imagine what happens to your knee when you load it when you run (which is essentially a repetitive, higher impact knee bend).

The answer initially includes VMO activation work and glute med strength and control work.  Once this can be achieved without body weight, then move on to body weight exercises, then exercises that increase the load (more weight, or no weight but involves steps ups or a jump....) and so on until you are ready to return to running.  Remember, running is a high impact activity.  It is not part of early rehab.  Find something else to do to maintain your CV fitness.  Swim, cycle, run in the pool....

ITB syndrome. A symptom, not the problem. 

How to run better up a hill (or several!)

Always looking for topics to blog about and my hubbie passed on this request from a Brutal 10km  (www.brutalrun.co.uk / @brutalrun) runner.

I'm not going to go into training programmes to improve your performance on the hills, although I will say one thing: kenyan hill reps.  Google it!

What I thought I would consider are the importance of various parts of the running technique that are important for a good efficient hill climb and how you can train, as far as strength and conditioning is concerned, to promote that good technique.

Firstly though, the less useless body mass you carry, the faster you will climb the hill.  It's all about the power to weight ratio.  So much is obvious! 

Getting a lower body fat percentage aside, the next thing to consider is the running style.  In my previous blog I discussed the most efficient running technique and this holds true for running on the flat or running uphill.  You're looking for a high cadence with good arm rhythm and drive, a fast hip flexion (leg lift) and a light, bouncy stride.

The importance of the upper body in all running and particularly uphill running is underestimated.  The upper body is intricately linked with the lower body through fascial bands across the front and back.  The right upper limb/quadrant drives the left lower limb/quadrant.  Good upper body strength and control will translate to a more efficient drive through the opposite leg.  This is achieved through the 'sling' effect (google...) and a way to promote this is through doing posterior chain exercises which I have already alluded to in one of my first blogs. 

A good way to feel the effect of the upper body on the lower body is to do sprint training or short hill reps.  Watch any 100m runner and you will see the effect in action. 

It is in fact possible that if you have had an injury in your lower leg, the opposite arm will overwork and can become strained/injured.  I saw a case such as this today in clinic.  Right shoulder pain secondary to left leg weakness (which was due to a brain injury following a blunt object to the poor persons head..... thankfully the person is back to complete physical fitness...barring the right shoulder pain!).

So - run lighter, run more efficently and train your upper body and posterior chain and you will master those hills.  And go and do some Kenyan Hills!

Case(s) of the day!

Well, today has been a plantar fasciitis day.  Sometimes it goes like that.  Everyone who walks through the door seems to have heel pain!

And today was a good day to remember that sometimes the pain that you get is actually a symptom of a problem elsewhere up the chain... and plantar fasciitis is a good example of just that!

So recalling today's case.  Heel pain for 20 months!  Has had to give up running.  Two steroid injections to heel, a 5 week course of shock wave therapy, one visit to an Orthopaedic surgeon, many visits to various physios, a course of acupuncture (at great cost), a chiropracter and a podiatrist.  And still heel pain.

So what do we find today?

Yes, heel pain.  But what else....well.... a right calf tear about 2 years ago (heel pain is on the right) with no rehab after the tear.  Ankle injuries playing hockey (although can't remember what side). 

On examination: a stiff right talocrural (ankle) joint, a stiff subtalar joint (lower part of ankle/foot joints), a stiff midfoot and a 'dent' in the medial side of the right calf where the medial gastroc should be!  Poor glute activation, poor glute max strength on the right, poor hamstring strength on the right (and left but to lesser extent).  And a positive slump test with evidence of neural tethering with the right foot held into eversion as the knee is extended. 

Ultrasound showed a right medial head of gastroc with a significant are of scarring as well as a thickened and disorganised plantar fascia.

The plan:
1) calf strength work
2) glute activation and strength work
3) hamstring strength work
4) physio mobilisation to the stiff right ankle (subtalar joint, talocrural joint, midfoot joints)
5) massage and acupuncture to the right medial gastroc to help allieviate some of the scarring.
6) no impact work - no running - running in the pool only, cycling if able, cross trainer if able, swimming
7) balance and proprioception
8) neural 'flossing' exercises

I can't guarantee it will work.  It's been a long time.  But I am convinced that the heel pain is a symptom...the sore throat equivalent of having a virus...with the virus being the stiff ankle and weak calf muscles. 

Most pain is secondary to an injury.  But that injury may be being provoked by a problem elsewhere and until that is dealt with the injury will remain.  Often the case in 'overuse' or 'overload' injuries.  The clue is in the title!

And sorry - next time I'll get a picture to make it more interesting!  If you want some pictures then just google (image) plantar fasciitis!

Desirable technique for running

The more efficiently you run the faster and longer you can run.  So running efficiency or economy are key.  And part of this economy of effort can be derived from running form. 

We are all different so there will never be a perfect answer.  Just watching the olympics in the past few days has confirmed that there are many body types and many ways of moving those bodies.  However, watching the 5000m final you can certainly start to put a few things together!  Number one - they aren't carrying any excess weight!  Simple!?

Other desireable hallmarks of an efficient running style include:
1) relaxed shoulders,
2) good use of arms (activating the posterior chain muscles) - with the elbows not coming forward of the body, the arms not crossing the midline at the front, a good rhythmical arm swing.
3) a relatively upright posture with a natural curve to the spine - cervical spine extension, thoracic flexion, lumbar extension - creating a spring.
4) the pelvis held in neutral beneath the natural spine curve - and held well by the right core muscles - NOT the rectus abdominus, diaphragm, gluteus maximus and hamstrings - these should be used for their purpose - breathing, running...
5) a good fast leg lift (hip flexion) - this helps to bring the heel up behind the body and allows the hamstrings to whip the leg through with less effort.
6) a quiet, light stride (no heavy heel strike and no 'spongy' running i.e. getting no 'lift' out of the footstrike
7) a fast cadence - shorter, faster more efficient strides with less energy lost and less force absorbed.
8) footstrike beneath the body, not in front, preferably with the midfoot.  The heel causes a braking force and is less efficient.

This isn't a comprehensive list.  Just a few ideas.  Concentrating on just a few of the above will help others to work of their own accord e.g. concentrating on a fast leg lift will encourage a good heel lift with little hamstring effort and this will help to bring the leg through.  Concentrating on good, rhythmical arm movement (elbows back) will help to activate the posterior chain (arms, back, bum, hamstrings) which 'sling' across the body and aid the opposite leg as it moves. 

And to get the posterior chain going you can use the following exercises:
1) good mornings
2) single leg romanian deadlifts
3) sling twists
4) nordic hamstrings
5) hamstring bridges (a different degrees of knee flexion - 90, 45, 0)

All of the above are available if you 'google' them, I am sure!

Back after a break!

Just had a quick look at my last posts and I should probably add that I have moved posts and now work as the SEM (Sport and Exercise Medicine) Doctor at the Regional Rehabilitation Unit in Aldershot, caring for injured Service Personnel. It's a great job, working with a fantastic team of Physios and Rehabilitation Instructors (Serving Physical Training Instructors specialising in sports therapy and rehab).   

I am also still running and racing with my main sport being Orienteering.  And this year I raced at both the World Orienteering Champs as well as the World Masters Orienteering Champs...yes, getting a bit older!  And I performed well at the latter and was very excited to win two silver medals at the World Masters in Germany in June. 

Running form, core strength and injuries.

I've been considering back pain and hamstring pain in relation to running and physical activity and a pattern is very clear with regard to how people 'set' their pelvis in order to allow the movement of their legs to move their body forward i.e how they achieve a 'stable core'.

The normal position of the lumbar spine is to have a natural curve - a degree of extension is normal.  However, if you overload the spine, either because you have poor core stability and glut strength or because you carry extra weight e.g. soldiers carrying heavy loads whilst running/marching then you have to find another way to stabilise the pelvis.  This can result in the adoption of a flexed spine in the case of carrying extra weight - in order to move the centre of gravity forward and allow the carrying of the extra load.  This then puts excess load on the lumbar spine in a way that it doesn't like to be loaded - with the loss of the lumbar curve.  The pelvis is also tucked under (posterior tilt), adding to the flattening the lumbar spine but allowing the gluts and proximal hamstrings to lock the pelvis tight and provide stability to the pelvis that can't be supplied by weak or overloaded core muscles. 

The result?  Low back pain and/or proximal hamstring problems and reduced performance - because the glutes and hamstrings are unavailable to help drive you forward because they are locked tight.  In order to get forward propulsion the calves/achilles/foot fascia can then be overloaded and results in other overload injuries further down the chain.

So what is the answer? Understand the importance of 'core stability' and develop the strength and control in the core that you need so that it is not overloaded in your activity of choice.  It is important to also correct maladaptive postures e.g. the posterior pelvic tilt, tight glutes/hamstrings, flattened lumbar spine.  This brings to mind the importance of stretching and a good understanding of the most desirable posture.  It is critical that the correct posture is understood as it needs to be adopted whilst undertaking strength and conditioning exercises for the gluts and core.  If it is not adopted then the wrong muscles will be trained and the improper posture reinforced and perpetuated.

It is hard to work this out on your own.  You need to see a good physio/biomechanist/sports therapist who understand the human form and can you help to understand how your body moves.  I would argue that almost all overload injuries have their basis in repetitive less than desireable body movement. 

I will go into the desirable body position, what exercises you can do to strengthen your core and glutes and how to stretch at another time.  But for the time being I just want to conclude by saying that when you do get the movement right, you will know because when you run, you will feel the drive and flow and it's good.