Hip Archives - Page 2 of 2 - Orthowell Physical Therapy

By admin 0 Comments All, Clinicians, Elbow/Wrist/Hand, Elbow/Wrist/Hand, Foot/Ankle, Foot/Ankle, Hip, Knee, Knee, Other, Pain Management, Pain Management, Patients, Running, Running, Shoulders, Shoulders, Special Techniques, Special Techniques, Spine, Uncategorized

PUMP YOU UP!!

So how important is resistance training? I have had the privilege of working with one of my peers, a fellow PT, and strength and conditioning specialist, Mike Stare from Spectrum Fitness in Beverly, both professionally as well as personally. Mike helped to redirect MY fitness program while I was recovering from my knee injuries 1.5 years ago. Mike is on top of his game from a fitness training standpoint. He has devoted a lot of time and resources in developing an evidence-based approach to fitness and weight loss in ALL age groups. You can see this for yourself at his website. It is important for clients in a fitness program as well as our patients in physical therapy at OrthoWell to understand HOW to strengthen muscles.

The physiological principle of “overload” is what makes the difference between strength gains and stagnation. Resistance training is hard work! I tell my patients “If it’s easy, then you’re doing something wrong!” Is it true that people will lose 5-10% of muscle strength in every decade of life after the age of 40? Studies have shown that people can retain 100% of their muscle mass and strength from age 40 through their 80s with exercise! (Wrobelski, A. et al. The Phys and Sports Med, Sept 2011) You can read more on the Anti-Aging movement at Mike’s BLOG as well.

However, during exercise, you need to challenge your muscles physiologically. You need to provide a “load” that goes “over” your muscles comfort zone. In order for a muscle (including the heart) to increase strength, it must be gradually stressed by working against a load greater than it is used to. So how do you do this? There are many books and magazines such as Muscle Fitness that advocate all kinds of strategies for maximizing strength and muscle mass. Strength gains can be accomplished by performing a one-repetition maximum as well as via the typical 10 rep set approach. My approach, with the fine-tuning of Mike, is to instruct my patients in 2-3 sets of 8-12 repetitions per exercise. The most important factors to consider are the utilization of proper technique in order to isolate the specific muscle as well as to use the idea of the “loss of technical form” as your maximum output point. By the time you reach the 8-12th rep you should be tiring and on the verge of a loss of technical form. You should not work to fatigue as this will compromise your technique and become a safety concern. Regarding the frequency of strengthening exercise, studies show that strength gains are maximized at a frequency of 2-3x per week. The American College of Sport Medicine (ACSM) recommends working out a MINIMUM of 2x per week at an intensity that is equal to 70-85 percent of your one rep maximum (maximum weight you can use for one rep) for 8-10 reps and 1-3 sets. A program that comprises repetitions over 12 is considered endurance training. For cardiovascular benefits, the ASCM recommends exercising for a frequency of 3-5 times per week, at an intensity equal to 60-85 percent of your maximum heart rate for a time of 20-60 minutes. Research has shown that you’ll get the same beneficial results by exercising at 50-60% of your maximum heart rate that you would get exercising at an intensity 80% of your maximum heart rate.

At OrthoWell, as part of your physical therapy, we get you started on a strengthening program that targets your problem area. Finding the right practitioner to design a complete, individualized fitness program can be a very rewarding thing and Spectrum Fitness is definitely one of our choices. As Mike points out, “If there is one thing to do to improve the quality of life as we age, strength training would be it.”

For our athletes and runners, don’t forget that strength training has been PROVEN to enhance athletic performance. Read the following to get the facts!

-A University of Alabama meta-analysis of the endurance training scientific literature revealed that 10 weeks of resistance training in trained distance runners improves running economy by 8-10%. For the mathematicians in the crowd, that’s about 20-24 minutes off a four-hour marathon – and likely more if you’re not a well-trained endurance athlete in the first place.

-French researchers found that the addition of two weight-training sessions per week for 14 weeks significantly increased maximal strength and running economy while maintaining peak power in triathletes. Meanwhile, the control group – which only did endurance training – gained no maximal strength or running economy, and their peak power actually decreased (who do you think would win that all-out sprint at the finish line?). And, interestingly, the combined endurance with resistance training group saw greater increases in VO2max over the course of the intervention.

-Scientists at the Research Institute for Olympic Sports at the University of Jyvaskyla in Finland found that replacing 32% of regular endurance training volume with explosive resistance training for nine weeks improved 5km times, running economy, VO2max, maximal 20m speed, and performance on a 5-jump test. With the exception of VO2max, none of these measures improved in the control group that just did endurance training. How do you think they felt knowing that a good 1/3 of their entire training volume was largely unnecessary, and would have been better spent on other initiatives?

-University of Illinois researchers found that addition of three resistance training sessions for ten weeks improved short-term endurance performance by 11% and 13% during cycling and running, respectively. Additionally, the researchers noted that “long-term cycling to exhaustion at 80% VO2max increased from 71 to 85 min after the addition of strength training”

By admin 0 Comments All, Clinicians, Foot/Ankle, Foot/Ankle, Hip, Knee, Knee, Other, Pain Management, Pain Management, Patients, Running, Running, Special Techniques, Special Techniques, Uncategorized

Foam Rolling Technique

As most of you know, a very important part of our practice is the treatment of soft tissue dysfunction. This may be in the form of a muscle “knot”, chronic scar tissue, or post-surgical stiffness. We have many names ie “the doctors of knotology” and “the Marquis de Sade” to name a few. In spite of the many terms of endearment, at OrthoWell, we get our patients better- Faster! because of our approach. A very important part of your recovery has to do with your home program. Every conditioning program should include stretching, strengthening, cardio, and a close fourth should be self-massage and/or self-mobilization. Many of you have experienced “the twins” (my double tennis ball massager) as well as the foam roller. It is important to address your chronic “knots”, scar tissue, and muscle sensitivities in order to promote optimal tissue dynamics and to prevent future pain syndromes related to poor tissue dynamics.

The following video highlights our foam rolling strategy for your lower extremities. Each muscle group should receive 5-10 passes along the foam roll. The amount of weight you impart upon the roll will be dictated by your tolerance. Yes, this should hurt! Only mild to moderate pain, nothing severe. Use your arms and opposite leg to control the pressure being applied. Try to identify key areas along the way that may need additional passes. Yes, over time, the pain will subside and your pressure will increase. Consistency is the key. Ideally, stretching and self-massage should happen daily. Here is a run down of what is happening in the video.

1. In the first part of the video, I am treating the quadriceps. Longer muscles need more attention. Perform 5-10 passes each at the upper end, middle, and lower end of the muscle.

2. Turn 45 degrees and perform the same treatment at the junction between the quadriceps and iliotibial band(ITB). Pay close attention to the lower end near your patella.

3. Turn another 45 degrees and, in the same manner, treat directly along all three aspects of the ITB.

4. Next, turn over and treat your upper glute area. Cross one leg over the other as shown. The leg that is crossed is the side you are treating. Perform 5-10 passes.

5. Move down to the hamstrings and treat the upper, mid, and lower ends. Place your opposite leg on top of the treatment leg in order to impart more pressure.

6. Next, treat the calf muscle. Place the opposite leg on top for more pressure. Treat the entire length of the calf. You can also perform an up/down ankle movement in order to help glide the stiff tissue while imparting pressure onto the roll.

7. Finally, treat the inner thigh or adductor muscle group. It may be easier to use the 6” roll to treat this area effectively. You can purchase a white 6” roll which is the same material as the 4” or you may purchase the black roll which is firmer than the white.

Keep on rollin’

By admin 0 Comments All, Article Reviews, Clinicians, Elbow/Wrist/Hand, Foot Orthotics, Foot/Ankle, Foot/Ankle, Hip, Knee, Other, Pain Management, Pain Management, Patients, Running, Running, Shoulders, Shoulders, Special Techniques, Special Techniques, Spine, Spine

KinesioTape-The Evidence

I have received several comments from bloggers that “there is no evidence” regarding the effectiveness of Kinesiology Taping or KinesioTaping Techniques. I would like to share with you some very detailed clinical study outcomes that are present, and copied here, from the SpiderTech website. This post is definitely more clinical in nature, but it can certainly help any interested patient or practitioner in understanding the evidence behind the WHY and HOW of KinesioTaping.

The Clinically Proven Effectiveness of Kinesiology Taping

Taping is widely used in the field of rehabilitation as both a means of treatment and prevention of sports-related injuries. The essential function of most tape is to provide support during movement. Some believe that tape serves to enhance proprioception and, therefore, to reduce the occurrence of injuries. The most commonly used tape applications are done with non-stretch tape. The rationale is to provide protection and support to a joint or a muscle. Utilizing existing stretch tape, investigators have shown clinical improvement in patients with grade III acromioclavicular separations, anterior shoulder impingement, and hemiplegic shoulders. In recent years, kinesiology tape has become increasingly popular as a therapeutic treatment option in North America and Europe. Kinesiology tape was developed in the 1970’s and was engineered to mimic the qualities of human skin. It has roughly the same thickness as the epidermis and can be stretched between 130% and 140% of its resting length longitudinally. The application techniques were developed through the use of applied kinesiology taping, which
logically gave the therapy and material its name. The tape reportedly has several benefits, depending on the amount of stretch applied to the tape during application: (1) to provide a positional stimulus through the skin, (2) to align fascial tissues, (3) to create more space by lifting fascia and soft tissue above the area of pain/inflammation, (4) to provide sensory stimulation to assist or limit motion, and (5) to assist in the removal of edema by directing exudates toward a lymph duct. The clinical information on kinesiology tape suggests improved function, pain, stability, and proprioception in pediatrics and patients with acute patellar dislocation, stroke, ankle and shoulder pain, and trunk dysfunction. The respective information comes from case series and pilot studies, the most important of which are summarized in the following:

In a prospective, randomized, double-blinded, clinical trial using a repeated-measures design Thelen et al. investigated the clinical efficacy of kinesiology tape for shoulder pain. Forty-two subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to 1 of 2 groups: A therapeutic kinesiology tape group or a sham kinesiology tape group. The therapeutic kinesiology tape group showed immediate improvement in pain-free should abduction after tape application. It was concluded that kinesiology tape may be of some assistance to clinicians in improving pain-free active range of motion immediately after tape application for patients with shoulder pain.

In 2009, Fraizer et al. examined in a case series the clinical outcomes for patients with shoulder disorders who were treated with a comprehensive physical therapy program that included kinesiology taping techniques. Five patients
were treated with this taping method among other interventions. All patients demonstrated clinically important improvements in function. The authors concluded that kinesiology taping should be considered as an optional clinical
adjunct in the treatment of shoulder pain as part of a comprehensive physical therapy regimen.

Also in 2007, Yoshida et al. studied the effect of kinesiology tape on lower trunk range of motions. Thirty healthy subjects with no history of lower trunk or back issues participated in the study. Based on their findings, the authors determined that the application of kinesiology tape applied over the lower trunk may increase active lower trunk flexion range of motion.

In 2007, Lie et al. studied the application of kinesiology tape in patients with lateral epicondylitis. The experimental results indicated that wearing kinesiology tape causes the motions of muscle on the ultrasonic images to be enhanced which the authors believe to indicate that the performance of muscle motion was improved.

The effect of taping using kinesiology tape in an acute pediatric rehabilitation setting was investigated in a 2006 pilot study by Yasukawa et al. The purpose of this pilot study was to describe the use of the kinesiology tape for the upper extremity in enhancing functional motor skills in children admitted into an acute rehabilitation program. Fifteen children (4 to 16 years of age), who were receiving rehabilitation services participated in this study. The improvement from pre- to post-taping was statistically significant. These results suggest that kinesiology tape may be associated with improvements in upper-extremity motor control and function in the acute pediatric rehabilitation setting. The authors concluded that the use of kinesiology tape as an adjunct to treatment may assist with the goal-focused occupational therapy treatment during the child’s inpatient stay.

In 2009, Tsai et al. evaluated the effects of a bandage replacement by kinesiology tape in decongestive lymphatic therapy (DLT) for breast-cancer-related lymphoedema. Forty-one patients with unilateral breast-cancer-related lymphoedema for at least 3 months were included in this study. The study results suggested that kinesiology tape could replace the bandage in DLT, and it could be an alternative choice for the breast-cancer-related lymphoedema patient with poor short-stretch bandage compliance after 1-month intervention.

As published in the journal Top Stroke Rehab., Jaraczewska et al. indicated that kinesiology tape could improve the upper extremity function in the adult with hemiplegia. The article discusses various therapeutic methods used in the treatment of stroke patients to achieve a functional upper extremity. The only taping technique for various upper extremity conditions that had previously been described in the literature is the athletic taping technique. The authors concluded that kinesiology taping in conjunction with other therapeutic interventions could facilitate or inhibit muscle function, support joint structure, reduce pain, and provide proprioceptive feedback to achieve and maintain preferred body alignment. Restoring trunk and scapula alignment after the stroke is critical in developing an effective treatment program for the upper extremity in hemiplegia.

The clinical efficacy of kinesiology taping in reducing edema of the lower limbs in patients treated with the Ilizarov method was investigated by Bialoszewski et al. The study involved 24 patients of both sexes subjected to lower limb lengthening using the Ilizarov method who had developed edema of the thigh or leg of the lengthened extremity. The mean age of the patients was 21 years. The patients were randomized into two groups of twelve, which were then subjected to 10 days of standard physiotherapy. The study group was additionally treated with kinesiology taping (lymphatic application), while the control group received standard lymphatic drainage. The application of kinesiology taping in the study group produced a decrease in the circumference of the thigh and leg statistically more significant than that following lymphatic drainage. It was concluded that kinesiology taping significantly reduced lower limb edema in patients treated by the Ilizarov method and that the application of kinesiology taping produced a significantly faster re-education of the edema compared to standard lymphatic massage.

Hsu et al investigated the effect of elastic taping on kinematics, muscle activity and strength of the scapular region in baseball players with shoulder impingement. Seventeen baseball players with shoulder impingement were recruited from three amateur baseball teams. All subjects were taped with both the kinesiology tape and a placebo tape over the lower trapezius muscle. The kinesiology tape resulted in positive changes in scapular motion and muscle performance. The results supported its use as a treatment aid in managing shoulder impingement problems.

By admin 0 Comments All, Clinicians, Foot Orthotics, Foot Orthotics, Foot/Ankle, Foot/Ankle, Hip, Knee, Other, Pain Management, Pain Management, Patients, Running, Special Techniques, Special Techniques

Reebok pays 25M – Kick in the Butt!

As an addendum to the my last post “Whats Up with the Shape-Ups?”, guess what happened to Reebok? They have to pay 25 million due to false “toning” claims. Talk about a kick in the butt!! Read on.

PORTLAND, Ore. — Reebok will need to tone down advertising for its shoes that claim to reshape your backside.

The athletic shoe and clothing company will pay $25 million in customer refunds to settle charges by the Federal Trade Commission that it falsely advertised that its “toning” shoes could measurably strengthen the muscles in the legs, thighs and buttocks. As part of the settlement, Reebok also is barred from making some of these claims without scientific evidence.

“Settling does not mean we agree with the FTC’s allegations,” Dan Sarro, a Reebok spokesman, said in a statement Wednesday. “We do not. We have received overwhelmingly enthusiastic feedback from thousands of EasyTone customers.”

It’s the latest controversy surrounding so-called toning shoes, which are designed with a rounded or otherwise unstable sole. Shoemakers say the shoes force wearers to use more muscle to maintain balance and consumers clamored for them, turning toning shoes into a $1.1 billion market in just a few years. Companies such as Reebok, New Balance and Skechers have faced lawsuits over their advertising claims. But the FTC settlement, announced Wednesday, is the first time the government has stepped in.

Reebok International Ltd. makes a range of toning products, including its RunTone running shoes, EasyTone walking shoes and flip flops and some clothing. The company, which is owned by Adidas AG, said that its toning shoes were one of its most popular product launches ever when they debuted in 2009. The company marketed them heavily with ads featuring women in short shorts and with shapely bottoms; one ad even said the shoes would “make your boobs jealous”.

The FTC took issue with Reebok’s ads that claimed its EasyTone footwear had been proven to lead to 28 percent more strength and tone in the buttock muscles and 11 percent more strength and tone in hamstring and calf muscles than regular walking shoes. The FTC said it could not disclose if it was pursuing similar actions against other shoe makers.

“We think this is a real victory for consumers,” said Dana Barragate, an FTC attorney involved in the case. “We hope it sends a message to businesses that if they are going to make claims they must be justified.”

Shoe makers, including Reebok, have funded studies and say they have anecdotal evidence that proves they are effective. Several experts have questioned their validity and the American Council on Exercise, a nonprofit fitness organization, conducted a study that found toning shoes failed to live up to the claims of shoe makers. However, the council said the shoes could be beneficial to one’s health if they motivate people to get moving.

Christopher Svezia, with the Susquehanna Financial Group, said many shoemakers have changed their advertising approach as criticism has mounted. “The emphasis has moved to fitness instead of making these kinds of claims and promises,” he said. “The question is who is next and how much is it going to cost them.”

The industry has faced other issues. There have been some injuries reported by wearers who have found themselves with shin splints, twisted ankles and sore muscles from the new gear and motions. Shoe makers suggest new wearers ease into wearing them.

Toning shoes were once the fastest-growing segment in the footwear industry, but recently lost some ground. SportsOne Source Group said that the $1.1 billion market of 2010 is expected to fall about 40 percent to $650 million in 2011 after Skechers flooded the market with products, forcing prices down. However, SportsOne Source said the number of shoes sold is only expected to fall 5 percent, suggesting there is still fairly strong demand.

Rebecca Sayre of Seattle, who bought a pair of Skechers more than a year ago, said they made her legs stronger and posture better. But, she says: “They’ve lost their luster.”

Story posted 2011.09.28 at 08:41 PM EDT

By admin 0 Comments All, Clinicians, Foot Orthotics, Foot Orthotics, Foot/Ankle, Foot/Ankle, Hip, Knee, Other, Pain Management, Patients, Running, Running

So what’s up with the Shape-Ups?

So what’s up with the claims made by these toning shoes??

I’m sure that you all have seen advertisements for the new rage in footwear…”toning” shoes. Several manufactures such as Shape-Ups by Skechers, MBT shoes, and EasyTones by Reebok have made unsubstantiated claims of increased gluteal activation and improved muscle tone as a result of wearing their products. A recent study sponsored by the American Council on Exercise compared 12 patients walking in “toning” shoes to 12 patients walking in traditional walking shoes. Researchers used electromyography (EMG) to evaluate muscle activity in several muscles of the lower extremity including the calf, quad, hamstrings, glutes, low back paraspinals, and the abdominals. The results indicated that none of the 3 studied brands of “toning” shoes exhibited a statistically significant increase in muscle activation. The researchers concluded that there is “simply no evidence” in their study to substantiate the “toning” claims made my the 3 shoe manufactures.

So why is that some patients feel better in “toning” shoes? These shoes are constructed with a rounded or rocker-bottom sole. This type of sole is designed to allow you to “roll” from one step to the next. It would thereby get you to transition more quickly from heel strike to toe-off and, as a result, decrease the amount of time that you are bearing weight on your midfoot. It would lessen the impact load on an arthritic or painful midfoot. It may also limit the amount of bend that is occurring in a painful or arthritic toe.

And: The heels of these shoes are very soft and may decrease the impact load on a painful heel.

And: Because of the raised apex of the rocker-sole, it feels to some of my patients that they are bearing more pressure against their arches thereby decreasing the weight bearing on the heel and the forefoot.

And, lastly: If you watch someone with “toning” shoes walking from behind, you will notice how their ankles tend to look a little unstable due to the softness of the heel and the rocker-bottom effect. This may predispose the patient with a chronic weak ankle to acute sprains. However, it may also have a positive impact on neurologic retraining ie proprioceptive retraining of the foot and ankle. Pre and post balance testing for “toning” shoe wearers would be an interesting thing to test.

But anyways, “Different strokes for different folks”…just don’t be fooled by the claims.

By admin 0 Comments All, Hip, Knee, Patients, Running

How “HIP” is your knee pain?

“The knee bone’s connected to the…hip bone” may be your therapist’s greatest clue to solving your knee pain. How many patients have gone to physical therapy for knee pain and received an ultrasound & quad exercises only to be disappointed in his or her outcome? What exactly is the link between knee pain and hip weakness? What does the research tell us?

Patello-femoral pain syndrome (PFPS) (pain under the kneecap) is the most common condition seen in an orthopedic practice. It is the most prevalent injury in persons who are physically active. Iliotibial band syndrome (ITBS) is the second most common overuse injury in runners. Anterior cruciate ligament (ACL) injuries are one of the most common ligament injuries in people who engage in athletics. What common factor contributes to ALL of these orthopedic conditions? You guessed it!! Weak hips! Read on for the proof.

In a recent review of the literature, Reinman cited 51 articles that provide some degree of evidence correlating hip weakness to knee loading and knee injury. The position of the knee relative to the hip during weight bearing activities is a predictor of dysfunction. Excessive hip adduction and internal rotation (turning in of the knee such as being bow-legged) can adversely affect the motion and forces that act upon the entire lower extremity. This combined motion produces a “dynamic” knee valgus. A valgus force places a tensile strain on the iliotibial band as well as the soft tissue restraints on the inside of the knee, particularly the ACL and medial collateral ligament. Claiborne et al and Hollman et al have reported that reduced hip strength is related to greater knee valgus angles. In the presence of hip abductor weakness (muscle that raises your leg out to the side), the opposite hip may drop during single-leg support causing a Trendelenberg sign. This is especially apparent during a slow, “controlled” descent down a step. A great functional test!

Why is it that the incidence of ACL injuries and PFPS is greater in women? Prins et al concluded that females with PFPS exhibit impaired strength of the hip extensors, abductors, and external rotators. Chen and Powers report that females with PFPS exhibit excessive “dynamic” Q-angles, especially with descending stairs. Pollard et al states that females demonstrate insufficient utilization of the hip extensors due to decreased knee and hip flexion during a jump squat for example. This leads to increased quad activation in the presence of a valgus knee and localizes the impact load onto the patella to a much smaller surface area. Hence, more pain!

So what if you’re a runner? Ferber et al looked at 283 studies that examined running-related injuries and concluded that the connections between weak hips and running were far more conclusive than the connection with flat feet (over-pronation). Interestingly, Earl et al prescribed a hip strengthening program to healthy female runners for 8 weeks and, in addition to improved hip strength, they measured a 57% decrease in pronation (flat foot) while running. Strengthen the hips and ditch the orthotics? Maybe.

If it hasn’t become obvious yet, hip weakness has been proven as a predictor of knee dysfunction. So in addition to your runs or to your crunches, you need a hefty dose of hip resistance training. Call us and we can get you started!!

By admin Clinicians, Foot Orthotics, Foot Orthotics, Foot/Ankle, Foot/Ankle, Hip, Knee, Pain Management, Pain Management, Patients, Running, Running

THE FORMULA FOR RUNNING PAINFREE

THE FORMULA FOR RUNNING PAINFREE

This article has turned out to be a labor of love. It has arisen out of my passion to discover the truth. The truth behind running as well as the truth behind MY potential as a runner. I hope that you find my commentary just as insightful as the research and as the writing has been for me. The references in my paper are from many on-line as well as off-line sources with an emphasis on the wealth of information presented by the authors of The Science of Sport. I have attempted to link all my references for your convenience.

THE TRUTH

I want to start with what’s called a little story branding. A sales pitch is all the more powerful when the salesperson has a story to share.

A story about losing 200 pounds if you are selling a diet plan.

A story about living a healthy lifestyle if you a cancer survivor.

My story started during my teens and early twenties- when I was a runner!

I trained with the track team and raced the 440 in high school. I ran recreationally in college. After graduating from physical therapy school in 1990, l decided, “I wasn’t built” for long distance running. I was convinced by my mentors and by my orthopedic education that my bowed legs, flat feet, and history of injuries were not conducive for running. I lost my way. I have run intermittently for distances of 1-2 miles since then in order to convince myself “that I could still do it”. I am now 43 years old and a runner once again. Of course, this has come with its costs. It felt so great to run again, almost Zen-like, and for 2 weeks I ran only 1 mile distances, 3x/wk at a 10-11 minute pace. As a heel striker, that long lost sensation returned…anterior shin splints. By the third and fourth week, the shin splints were abating and I increased my distance to 2 miles, 1.5 run and .5 walk. No problems. And then my competitive juices started flowing. I got out my stopwatch. Bad idea. Over week 5 and 6 I committed a cardinal sin, I increased both my distance and my speed. By week 7, I was running a 7.5-minute mile for 3 miles and had my inaugural return to a 5K within reach. I was feeling great! And then it happened. Sharp pain right knee and then the left. Shit!! Is all I could muster. Maybe my mentors were right after all?

I have done a lot of soul searching and a lot of research since “the pain”. I pride my physical therapy clinic in that we are students of proper, evidence-based technique. How could I have been so careless with my 43-year-old body? I was fearful that I tore my meniscus. It took 2 months to be able to jog down the hall without pain. It took another 2 months to be able to jog 1 mile again. But there was hope. I was not about to commit the same sin again.

Shortly after “the pain”, I had a colleague do a manual muscle test on my hips. I couldn’t believe how much of a wimp I was. This, of course, is a very common finding in the majority of runners that I treat as well. I “thought” that I was strong because of my 2x/wk workout in my gym, but I wasn’t doing nearly enough isolated strengthening. It is a common myth that “runners shouldn’t resistance train”. Now I have the research to prove that you SHOULD! I have been committed to a 2-3x/wk regimen of posterior chain exercises (glutes,hams,calves) and core stabilization exercises in order to break my chronic cycle of anterior dominance (quads,ant tibs) My runs were initially replaced with dynamic warm-ups, biking, and calisthenics during my strength re-building phase with a planned and progressive “couch to 5K” return to running. And guess what happened? I successfully returned to a 5K at the celebrated Thanksgiving Turkey Trot at Maudslay State Park in Newburyport, MA with a time of 24:38 and NO PAIN!! I agree with the mantra that “you should train to run, not run to train.” Of course, how and why you train will be one of the focal points of this book.

PASSION TO LEARN

The more that I read about running, study running technique, and learn from my own mistakes, the more emboldened I’ve become to run once again. Who we consult to determine the proper path in accomplishing our goals can be THE determining factor in success or failure. It certainly was for me. Every running coach has a different level of experience. Every physical therapist has a different level of experience. It is up to you to become the educated consumer, the informed runner, and to advocate for your own health and wellness. What I would like to do is to share my “education”. I have read the running literature extensively and wish to consolidate a wealth of information and reference as much as possible. I will present current thought and research behind the evolution of running, the evolution of running shoes, and the controversy and merits behind different running techniques. I will summarize the findings of my research by highlighting key points and strategies for unlocking your potential as a runner. So read on!!

THE EVIDENCE

In the United States, the running boom was triggered by the 1972 Olympic marathon victory by Frank Shorter. Running shoe companies blossomed almost over night. Until that point, running shoes were very minimalist. The running boom brought huge financial incentives to the running shoe industry. The public, to this day, continues to be influenced by various shoe companies assailing their product as the “next best thing”. By some accounts, it was the motive of Nike to promote the heel striking quality of its shoes and hence, the resulting heel strike generation. This is part the fact, and part the conspiracy theory, behind the true motives of running shoe companies. Despite the fact that many studies have been done on running, that running shoe “technology” has improved over the years, and that the average runner is much more informed about running than ever before, the frequency of running injures has not changed in the past 30 years. The latest studies suggest that anywhere between 40% and 70% of runners are injured every year. Regarding the claims of “enhanced performance”, “improved mechanics”, and “reduced injuries” made by advocates of different running techniques, there is NO scientific research to validate ANY of these claims. Unfortunately, there are pundits in the field who misrepresent and/or misinterpret the research to validate their own causes. So you need to be careful before drawing any premature conclusions. The bottom line is: we need more research!

One of the arguments put forward is that when it comes to running, we accept that ‘natural’ is best. However, to apply this “logic” to any other human activity such as swimming, tennis, dancing, or driving a car would sound totally strange, but not so for running. This is the running paradox. From an evolutionary standpoint, some anthropologists state that we used to run to survive and that each person develops his or her most comfortable, effective and efficient stride. Those that were efficient survived and those that weren’t didn’t. So to apply the logic that we have to be taught to serve a tennis ball to we have to be taught how to run is the topic of much debate. The perception that we all run “naturally” is what advocates of Pose, Chi, and barefoot challenge. The unfortunate consequence of the debate is that injury rates have stayed the same despite improved coaching, medical care, and better running shoes. So where do you draw the line between what is learned naturally and what is taught technically? That is the million-dollar question.

So what does some of the research say regarding running shoes? Interestingly, in 1989, Dr. Bernard Marti published a paper in which he surveyed 4,358 runners who participated in a 16km race and found that runners who ran in shoes costing more than $95 actually were twice as likely to get injured than runners who ran in shoes costing only $40. Of course it’s impossible to conclude that “expensive shoes” cause injuries, but it is certainly a point well taken by the minimalists in the crowd. In addition, Clingham et al, 2008 found that runners who ran in the most expensive shoes were just as likely to get injured as those who ran in cheap shoes. In Kong et al, 2009, the maximum vertical force and the maximum loading rate were no different in new shoes versus old shoes. In another study by Knapik et al, 2010, after controlling for physical fitness and age, you do no better at reducing injury rates than if you just give every runner the same shoe. So the idea of prescribing certain running shoes for certain motion control features is not validated by research either. In a 2008 research paper for the British Journal of Sports Medicine, Dr. Craig Richards revealed that there are NO evidence-based studies that demonstrate that running shoes make you less prone to injury. Is it any wonder why barefoot advocates find it easy to condemn the 25 billion-dollar running shoe industry?

So what is the rationale behind barefoot running? In Born To Run, Chris McDougall advocates the Running Man theory in which humans evolved to be long distance runners. He points out that homo sapiens evolved the ability to thermo-regulate via sweating and subsequently exploited their ability to actually run down and exhaust large game i.e. persistence hunting. Anthropologically, we are all born to run! From a developmental standpoint, we tend to think of running as automatic. We progress from crawling to walking to running. An innate process, right? However, the day that we start wearing shoes is the day that our feet start to change. D’Aout et al, 2009 shows that the “natural” shape and function of the foot changes with chronic shoe wearing. This is a valid argument for why it would be difficult to go from shoes to barefoot running. Another argument is that individuals in barefoot societies are barefoot ALL day. They have time to build the proper foundation. During barefoot running, the ball of the foot usually strikes the ground first and, due to the direct sensory stimulation, immediately sends signals to the brain about forces and surface irregularities. Take away this direct contact by adding a cushioned substance and you immediately fool the system into underestimating the impact. Footwear manufacturers were well aware that the shock of impact was the cause of running injuries. What they incorrectly reasoned was that the way to decrease these forces was to interpose a soft impact absorbing midsole between the foot and the ground. In 1988, Hamill and Bates showed that as running shoes lose their cushioning through wear and tear, subjects improve foot control on testing. In one of their most widely publicized studies, Robbins and Waked (1997) examined the effect of advertising on landing impact. They concluded that runners who THINK that they are receiving more shock attenuation in their shoes actually impact harder and may be predisposing themselves to injury. So how would a normally shod runner transition to barefoot running? Very carefully. Once again, you need to train to barefoot run, not barefoot run to train. Is it possible to rehabilitate the weakened muscles of a normally shod runner? In a study by Dr. Robbins (1987) he asked 17 normally shod recreational runners to gradually increase barefoot activity both at home and outdoors over a period of several weeks and to maintain barefoot activity for about four months. The runners’ feet were examined, measured and x-rayed at regular intervals to detect changes. Results showed marked improvement in the anatomy and function of the arch. The authors concluded that the normally shod foot is capable of rehabilitation of foot musculature. So, yes, it is possible to strengthen the foot.

As I dug deeper to find validation for proper foot striking, I came across a study in the journal Nature by Harvard’s Daniel Lieberman entitled “Foot strike patterns and collision forces in habitually barefoot versus shod runners“. The study found that habitually barefoot endurance runners most often land on the forefoot, sometimes land with a flat foot (mid-foot strike) or, less often, on the heel (rear-foot strike). In contrast, habitually shod runners mostly rear-foot strike. His study found that heel striking generates a significant impact transient, a nearly instantaneous, large force. In forefoot striking, the collision of the forefoot with the ground generates a very minimal impact force with no impact transient. He also demonstrated that FF striking decreases the eccentric load on the knee yet increases the load at the ankle due to the plantar-flexed position of the foot at impact. The author is also quick to confirm what others have said in that there is “no evidence on injury prevention or cause with heel or fore-foot striking”. Dr. Lieberman has a very informative websiteto learn more. You can also watch a video of Dr. Lieberman explaining and demonstrating the results of his study. Barefoot running has inspired people like Barefoot Ted and Michael Sander to share their enthusiasm as well.

So what about the Pose Technique and Chi Running? The fundamental principles of Pose and Chi Running are taken directly from their respective websites. Regarding the Pose technique, “The Running Pose is a whole body pose, which vertically aligns shoulders, hips and ankles with the support leg, while standing on the ball of the foot. This creates an S-like shape of the body. The runner then changes the pose from one leg to the other by falling forward and allowing gravity to do the work. The support foot is pulled from the ground to allow the body to fall forward, while the other foot drops down freely, in a change of support. ??This creates forward movement, with the least cost (energy use), and the least effort. The end result is faster race times, freer running and no more injuries!” The idea behind Pose is that you create forward momentum by falling forward like a pole, hence, using the pull of gravity. You pull your foot from the ground as you begin to fall and then let gravity return your foot to the ground. You move the legs by PULLING up instead of DRIVING your legs forward. The inventor of Pose, Dr. Romanov, states that the “fall and pull is the essence of the running technique”. He demonstrates the technique in this video and performs an analysis of Haile Gebrselassie in this video. Regarding the Chi Method, “The Chi Running program teaches people bio-mechanically correct running form that is in line with the laws of physics and with the ancient principles of movement found in T’ai Chi. Chi Running technique is based on the same principles and orientation as Yoga, Pilates, and T’ai Chi: working with core muscles; integrating mind and body; and focused on overall and long term performance and well-being.” Here is a video on Chi Running. So what’s the difference? Not much. Chi seems to be a re-packaging of Pose philosophy with a “holistic” twist. They both advocate leaning to engage the pull of gravity. Chi encourages a mid-foot strike and Pose a forefoot OR mid-foot strike. Chi purports to be more “holistic” and to rely more on your lean than the “fall and pull” with Pose. Subtle differences, for sure.

So what does the research say about running technique? Can you guess? There is NO research that correlates any reduction or any increase in injury to a specific running technique ie Pose, Chi, barefoot, or running shoes. Anecdotally, you hear about elite African runners who grow up barefoot, but choose to use running shoes. Abede Bikala won the 1960 Olympic marathon running barefoot, but went on to break the world record in 1964 with running shoes. If the Pose and Chi methods are valid, then one would expect that elite runners would tend to be more mid-foot or fore-foot strikers. Studies actually show the OPPOSITE. In Hasegawa et al., it was found that the vast majority (75%) of elite runners land on their heels. So what happens if you try to change a runner’s technique? In a studyperformed in Cape Town in 2002 on 20 runners, one week of intensive Pose training was able to change a great deal of biomechanical variables. The stride length, stride rate, knee joint angles and rate of loading were all changed. What happened next is that more than half of the runners broke down with calf muscle injury, Achilles tendon strains and other injuries of the feet. As always, the consumer has to be careful when they “buy” the product. The biggest problem may not be the instruction as much as the timing of implementation. How much time is required for proper adaptation? An interesting side-note is that nobody has yet done a study that changes a runner’s technique and then tracks him or her over many months, or years, to see how his or her injury rates change. Although this would be a very difficult study to control due to all the potential variables, it would certainly provide substantial evidence in the running technique argument.

THE RIGHT PLAN

The idea that one single technique should be applied to millions of genetically distinct runners may not be realistic. What is realistic, is applying the sound fundamental arguments made by advocates of the different running techniques as well as from the science of running biomechanics. Much of the running technique debate is based on the biomechanical analysis of elite runners – and with good reason. The authors of the Science of Sport blog eloquently state that “good running technique is first learned naturally, then refined through practice, and then subtle changes can be taught through instruction on a case by case basis…Finding a BETTER way to run is not the same as only ONE way to run.” An informed coach or even an intuitive runner can modify his or her technique in subtle ways. Just as in the golf swing, small changes can produce noticeable results. So where do we begin to make changes? There are so many factors that need to be considered in answering this question such as the results of the gait analysis, the presence of pain or injury, the experience of the coach, the goals of the runner. What I attempted to do was to list several key points for consideration based on the merits of all the research that I have done up to this point.

1. We want to minimize the energy expenditure to create the forward momentum of running. Therefore, it seems advantageous to utilize the pull of gravity and the concept of controlled falling as proposed in Pose and Chi. We should keep our center of mass forward instead of backward. Lean forward from your hips, not from the shoulders. Remember that you fall like a pole with inertia created at your center of mass i.e. hips/pelvis. If you are suffering from low back pain, maybe you are running too upright or even leaning backwards.

2. The foot strike is one of the most controversial issues. It makes sense that if you lean forward and keep your center of mass forward, that your forefoot would naturally land directly under your body. Jumping straight up and down is an example of keeping your center of mass directly over your base of support.

3. If you strike your foot too far out in front of your body, you are essentially “putting on the brakes”. Efficient running should mean minimal shock at impact with minimal effort to maintain our forward momentum i.e. inertia. As stated earlier in the Lieberman study and video, heel pain or knee pain may be the result of the 4x greater impact load that occurs with heel striking. So try forefoot or mid-foot striking instead.

4. Maybe we shouldn’t be concerned at all about how our feet strike the ground. Increasing tension at impact may lead to repetitive stress injury. One strategy would be to simply have the runner land in a “relaxed” manner on whatever part of his/her foot they choose, but to land more directly under his/her center of mass. If you ‘reach’ for the landing, then you will land more on the heel (unless you plantar flex, which is a BAD idea!), whereas if you allow your foot to land under the body, then you land more mid-foot. And maybe that’s all we need to know about foot striking!

5. We need to focus more attention on foot strengthening and proprioceptive (sensory) retraining. As stated earlier, we CAN “strengthen our arches”. I know this from my own experience in that I can now weight-bear 45 minutes without shoes on my hardwood floors and couldn’t stand more than 5 minutes without foot pain 6 months ago. It works, but it takes time.

6. You may want to consider switching to a lightweight shoe that provides less cushioning and no arch support. Racing flats are one example. Inquire at your local running shoe store about minimalist running shoes like the Nike Free. Start using these shoes at home, during your gym workouts and then progress to a walk-run program.

7. We need to stress that the only research validated reason for injury is improper training. A study by van Gent states that shoes and running technique are factors, but the only factor that is KNOWN to cause injury is training too long, too hard, too soon, or a combinations of all three.

8. We need to become less quad dominant in order to prevent the overuse that occurs from muscular imbalance. We need to add posterior chain, hip strengthening, and core stabilization exercises to our weekly routines. The link between hip weakness and faulty biomechanics can be read at Powers and Ferber.

9. “Drive your knees forward! Come on, pick em up!” is a cry often heard at track meets. The runner then overemphasizes stride length and works even harder on contracting the quads to drive the knee forward. Remember that over-striding forward causes deceleration. Instead, the runner may want to be instructed to increase his turnover, to LIFT his feet off the ground, and LEAN as advocated in Pose.

10. Keeping in mind all the stated research, the best approach to running technique may be a mixed approach. Respected running coach Vin Lananna has his runners perform part of their workouts in bare feet and stated, “When my runners train barefoot, they run faster and suffer fewer injuries”. (Born to Run, p.169). Gerard Hartmann,PhD,PT, who treats the best runners in the world, believes that the best injury-prevention advice that he’s ever heard is to “run barefoot on dewy grass three times per week”.(Born to Run, p.177)

11. In terms of barefoot training, being conservative is the key. Per the authors of The Science of Sport, you may want to start once a week at first. Limit the length of each run to 50% of your normal distance and break it up into intervals of about 5% with walking in between. For example, if your average run is 60 minutes, you should head out for 30 minutes, run for 2 minutes, walk for 1 minute, 10 times. Gradually increase the running from there; if you feel your feet, ankle and calves are up to it.

12. We need to realize that motion control shoes and foot orthotics may only have to be a temporary solution. I have fabricated custom foot orthotics for 20 years and can unequivocally say that they can reduce tissue stress, re-distribute pressure, and alleviate pain. The weaning away process is determined by the time and effort that the patient or runner puts into proper re-training.

13. It’s important not to increase the distance, frequency, and intensity of your running all at the same time. Don’t get too excited like I did. Make good, sound decisions.

14. Lastly, whatever change you implement, remember to listen to your body, use sound training principles such as not increasing your speed or distance by more than 10% per week, allow adequate recovery time, and protect your body-Your Temple-at all costs.

Good Luck!!

Chris Dukarski,PT

By admin 0 Comments All, Hip, Knee, Patients

The importance of closed-chain exercise.

Closed chain exercises for the lower extremities (exercise with you feet contacting the floor) should be an integral part of your rehabilitation program. They are important in terms of regaining dynamic stability and improving neuromuscular control. Co-contraction of the muscles on all sides of a joint occurs only thru closed chain or weight bearing activities. An effective program for a patient with an ACL tear of the knee should include exercises such as squats, lunges, and step-ups. A patient recovering from an ankle sprain should perform balance board activities. In terms of patello-femoral dysfunction or pain in the region of your kneecap, the literature describes a strong link between hip weakness (especially the hip abductors and external rotators) and P-F pain. Open chain exercises such as straight leg raises should be performed in every plane of motion. Closed chain exercises should incorporate multi-planar strengthening as well. The following exercises include hip abductor resistance during a functional squat exercise and hip adductor resistance during a lunge. Creativity is the key to devising a more functional and sport specific program.

At OrthoWell/WalkWell, we use evidence-based and creative strategies to get you better- FASTER! The following testimonial is from a recent “graduate”.

“I’ve had major ankle issues for over 15 years and have seen several PT’s and specialists but saw no progress until I came to WalkWell. After only 10 visits, I have made more progress than in the 15 years combined. The individual attention and rehab is without peer. And on the 8th day, God created WalkWell!” – Tom Lynch, Ipswich, MA

By admin 0 Comments All, Clinicians, Hip, Knee

CLOSED CHAIN CREATIVITY

Closed chain exercises for the lower extremities should be an integral part of your rehabilitation program. They are important in terms of regaining dynamic stability and improving neuromuscular control. Co-contraction of the muscles on all sides of a joint occurs only thru closed chain or weight bearing activities. An effective program for a patient with an ACL tear of the knee should include exercises such as squats, lunges, and step-ups. A patient recovering from an ankle sprain should perform balance board activities. In terms of patello-femoral dysfunction or pain in the region of your kneecap, the literature describes a strong link between hip weakness (especially the hip abductors and external rotators) and P-F pain. Open chain exercises such as straight leg raises should be performed in every plane of motion. Closed chain exercises should incorporate multi-planar strengthening as well. The following exercises include hip abductor resistance during a functional squat exercise and hip adductor resistance during a lunge. Creativity is the key to devising a more functional and sport specific program.

At OrthoWell/WalkWell, we use evidence-based and creative strategies to get our patients better- FASTER! The following testimonial is from a recent “graduate”.

Category: Hip