Do you run funny?….

…..Maybe, but does it matter?

As an advocate for video running analysis, I am also the first to say that we should not change a running gait pattern for the sake of it. There are pros and cons to changing a running gait, and it is important to understand these before making any changes. We must understand that although there is a textbook “normal”, most people, one way or another, fall outside of this! We need to understand when it is bad to fall outside of “normal” enough that the benefits of changing outweigh the risks. We as professionals, and people themselves should not just dabble in changes, as big problems can occurs that are hard to unravel. I have seen athletes themselves and under the direction of professionals change to an en-vogue running style which has resulted in an overload injury, even as bad as a stress fracture.

When might we want to change gait pattern:

• Certain aspects of technique are associated with certain injuries, or increased injury risk. e.g. narrow step width has been linked to ITB problems.
• Certain aspects of technique load up different joints more than others (see our blog article on foot-strike).
• Minimizing forces in one direction and improving them in another can potentially improve performance. e.g. reducing vertical oscillation of the center of mass will reduce energy lost in this direction and leave more energy available to transition you forwards.

What things might make us question the worth of a change?

There are some highly successful runners with very odd gait patterns. Even if their biomechanics are not optimal, in the presence of success, why should/would we change things? Let us consider a couple of examples:

• The English female runner Paula Radcliffe had a memorable head bobbing technique. I remember the talk on TV from former runners and coaches about this not only early in her career but throughout. In-spite of this, she became the female marathon world record holder, which she has now held for 12 years.

This picture of Paula Radcliffe shows a head in nice alignment with her body. Video below shows how her head bobs when she got the world record. Even though this was at the end of the race she always ran with her head doing this!

• The Kenyan female runner Priscah Jeptoo has a notable valgus (knock-knee) collapse during her running gait. In-spite of this, she has had great success and has just won the New York marathon.

In this picture you can see how Priscah Jeptoo’s right knee is collapsing in. When you watch the video below you can see how the knee doesn’t only fall in but the leg whips out into a dynamic valgus position.

In the case of a professional runner, would it be wise to change their mechanics in the absence of injury? At the peak of a successful career, such as these two runners, it is quite reasonable to council against change as there is potential that the change could cause problems, or reduce performance. If changes were to be made they would need to be small and off-season, with the runner being fully informed of the risk. A runner might chose to make larger more drastic changes if they are not performing to the standard they expect, or perhaps their competition has moved the goalposts. But, even with much research having been done on running and biomechanics, we cannot know the exact timing and technique changes that should be made for each runner. This is especially true as we know there is much variation in the human body from the text book “normal”. Some athletes will vary greatly from the norm but perform well and remain injury free. If they have been running from a young age the body’s tissues (tendon, muscle, ligament, bone) may have developed in a way to accept these biomechanics (we call this tissue adaptation), or they may have favorable genetics. This perhaps compares differently to the amateur who takes up running aged 30 who has biomechanics that does not fit the norm and also has tissue that cannot take the strain. Knowing these distinctions, and analyzing where someone is in their running/sporting career is a challenge that needs detailed examination and experience. This is why professional athletes should be very cautious in choosing the professionals they work with. There have been plenty of cases where athletes, chasing their next goal, have sought out people who promise the moon but instead deliver calamity. Outside of running, perhaps one of the most famous examples is Tiger Woods: Several sports professionals (see here for an example) feel that Tiger’s injuries have come from his continued pursuit of a better swing technique. His changes were not always small tweaks here and there, they were in-fact drastic changes. What were initially changes to improve performance led to injury and then changes made to offload one injury led to other problems. It is worth noting he worked with several coaches over his career, and from my reading at times pursued changes that they did not support. With respect to his injuries, you have to wonder how much more successful he may have been had he not made these changes. Who knows, we may have still been talking about him as a true contender.

Most people reading this blog are not professional athletes! But, just as with the professional runner, this is a discussion of risk vs reward. For the recreational athlete, whose income is not derived from running, you could argue the risk is much lower and the reward higher. Even for the high quality high-school or collegiate athlete I would suggest the same as there is a chance that performance will improve and the risk of a career hampering injury is lowered. It is easier for the body to adapt to changes at a younger than an older age. These suggestions for both recreational and high-school/collegiate runner are particularly true if changes are made in a controlled manner. We often talk about increasing distance, intensity, speed by no more than 10% in a week, but in-fact some of the recent research is suggesting a novice runner can increase by up to 30% in a two-week period¹. Sports medicine professionals need to present a case to the athlete, using a combination of evidence and experience, on the pros and the cons of the technique change being considered.

How can we change our running style?

First we need to have a thorough analysis, which I think should include physical and video examination. When I look at this analysis with a runner, there are many things that I see that stray outside of the “normal”. However, some things are more significant than others and may guide us to change a gait pattern. I often use the analogy of a puzzle: there are some large very important sections that if addressed will have a greater effect in producing the end result we are looking for such as improved speed, or reduced pain. There are also smaller sections, which may have lesser effects and may be less important to address.

Our examination may define puzzle pieces of weakness, tightness, or lack of motor-control (a dynamic movement such as Jepto falling into valgus). It is certainly not inappropriate to provide strengthening, stretching, or exercises relating to motor-control. We may also consider types of manual therapy, such as massage, manipulation, foam-rolling, and taping. However, doing just these types of interventions will likely not have the effect we want. In-fact in the past year I have had runners visit me for an opinion – they have had the above treatments, have had relief for a few days, weeks, even months, but their problem has recurred. To get more lasting and powerful results we should consider three research papers produced over the past four years by Rich Willy, an assistant professor and PT at East Carolina University.

One paper² studied a hip strengthening program (weight-bearing and non-weight-bearing progressive exercise program) on running mechanics and single leg squat mechanics of 20 uninjured females. The subjects had what we would clinically describe as abnormal hip mechanics. Having just come from a clinical background to working on his PhD, Willy had an expectation that the strengthening would cause changes to both squat and running mechanics. The research found that the exercises did increase muscle strength, and improve single leg squat mechanics, but the running mechanics were unchanged. Willy hypothesized that the exercises did not relate enough to running to affect a change. Willy also noted a limitation was that one of the exercise progressions was a single leg squat, so the improvement in the mechanics of that test may have been from neuromuscular development having done it as an exercise. In hearing him interviewed, he feels that the improvement in the squat may have been due to the instructions that the subjects were given. So in-fact, simple exercises might not actually make much change to running mechanics. This brings us nicely to two other studies his research group have produced with respect to the idea of cueing. In particular, they have looked at external cues and how they can affect running mechanics. Other research has found that external cues to have a greater ability to help us learn a new skill³ than an internal cue, and therefore make an initial change to biomechanics. Before we discuss these two studies, let’s quickly define these two types of cues:

• Internal cue: There is a focus on how a part of the body is moving, or what muscle is contracting.
• External cue: The focus is external to the body, or something externally that is acting on the body or the body is acting on.

The first study⁴ looked at a group of 10 female runners who had persisting patellofemoral (anterior knee) pain. These athletes were running at least 10k a week, had pain for 3+years, and had been examined and shown to have abnormal hip mechanics. They used 8 sessions of mirror retraining, asking them to increase the gap between their knees (external cue), and squeeze gluts (internal cue), to correct hip adduction mechanics (see more about these mechanics in our blog post here). The sessions started out at 15min with full feedback, and then increased to 30min by the end with reduction in mirror feedback time (1.5min at beginning, 1.5min in middle). Therefore the external cue was reduced during the training. The runners were followed for 3 months and all maintained their changes. With this they found good carryover from the improved running mechanics to single leg squat and stair descent. This contrasts with the lack of carryover from exercises we saw above. In the earlier interview with Willy, he explains that he was able to have some discussion with the athletes throughout the study and found that from the initial cues they had developed their own cues that worked for them.

We already mentioned that it is thought that the initial learning of a new skill is better achieved using external cueing. However, you do not want to be dependent on the external cueing to perform this skill forever, so I expect that there is some shift from a dependence on external to internal cues. There is likely a shift to a point where the neuromuscular control is so good for the task that it becomes automatic and the internal cues (or even external) are only needed when there is a different extreme or situation. A good example of this is how from time to time athletes need to reintroduce cues when they are able to run at a new pace they are not familiar with.

To further see the results of external cueing, let us look at a final paper by Willy⁵. Medial tibial stress syndrome (MTSS or shin splints) is known to be influenced by increased vertical loading and hip adduction. We know that increasing step rate improves these two issues, and therefore potentially reduces the risk of getting MTSS. To investigate this they studied 30 healthy runners who were at risk for MTSS. First they did video analysis of each runner and supplied them with a Garmin wireless accelerometer device. One randomized group was instructed for 8 runs to increase their cadence/step-rate by 7.5% over their preferred step-rate. Video analysis was conducted at the end of this period and once a month after the retraining. The study group, on average, increased their step rate by 8.6%, and reduced instantaneous and average vertical load by 17.9 and 18.9% respectively. They also reduced hip adduction by 2.9±4.2 degrees. All of these improvements were statistically significant, meaning these did not occur by chance. The control group had no changes in their measures during their 8 sessions of running self-paced without a device. Earlier I mentioned that changes needed to be gradual; notice how the target step rate increase was only 7.5%.

Conclusion:

Experience helps me to know when or when not to change a running gait; it also helps us to know what and how much to change. Even with experience, we have assumptions in how things work/occur and the latest research can sometimes confirm or disagree. In this case, like Willy, earlier in my career my focus was much more on strengthening, and cueing was less of a thought. I still think that strengthening and flexibility are important, but tying it to effective cueing is a game changer! Correct cueing strategies are a big part of my treatment of runners and other athletes. I have seen runners who, using cueing techniques such as above, have been able to increase their performance, some taking the clock back 5+ years! Just this weekend I saw the result of a runner who I had worked with who 3+ years of pain. She had some of the more common flaws, but also an odd flick during her swing phase. The changes we had made had helped her to run a new half-marathon PR, and she is hopefully on track for Boston qualification.

Hopefully she’ll be there 🙂

The advent and uptake of technology can be very helpful to athletes. Video running analysis helps us to better define issues taking the guesswork away from the analysis. Devices such as Garmin watches which help us monitor step-rate and vertical displacement are very powerful rehab tools. It has been a great experience working with some of my triathlon clients who have these top-of-range Garmin devices. They have been able to look at some of their data points from before they were a client to having seen me for a few sessions and are able to note the changes. It has been great to see an athletes reduce their vertical displacement from 12cm to 8cm over the period of a couple of months and see how at the same time their pace and pain have improved!

References:

1. Nielsen RØ, Parner ET, Nohr EA, Sørensen H, Lind M, Rasmussen S. Excessive progression in weekly running distance and risk of running-related injuries: an association which varies according to type of injury. J Orthop Sports Phys Ther. 2014;44(10):739-47.
2. Willy RW, Davis IS. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther. 2011;41(9):625-32.
3. Winstein C, Schmidt R. Reduced frequency of knowledge of results enhances motor skill learning. J Exp Psyc. 1990; 16:677–91.
4. Willy RW, Scholz JP, Davis IS. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clin Biomech (Bristol, Avon). 2012;27(10):1045-51.
5. Willy RW, Buchenic L, Rogacki K, Ackerman J, Schmidt A, Willson JD. In-field gait retraining and mobile monitoring to address running biomechanics associated with tibial stress fracture. Scand J Med Sci Sports. 2015;

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