This is the story of Susi, a talented local young runner who came to me for help with knee pain that had been preventing her from completing a marathon since 2009. Over the course of 6 months, I saw Susi for a running assessment and four follow-up appointments, and with hard work she was able to progress from running no farther than a half-marathon with pain, to running up to 15 miles pain-free. Along the way she also set running and cycling PRs, and, less than a year after her first appointment, she completed a marathon and in doing so qualified for Boston 2017.

The Story

Susi was one of my first patients after I opened PhysioWorks in March 2015. She enjoys and excels at long-distance running, and qualified for the Boston Marathon in 2009. However, knee pain had been preventing her from running Boston, or any other marathon, for the past five years! Susi had already tried surgery, physical therapy, as well as changing up her shoes and orthotics, but the pain had remained, limiting her to running half-marathons at the longest. During her first appointment, we outlined her goals – to run pain-free, reduce her risk of future injury, qualify (again) for the Boston marathon, and then keep on running until she’s 80+!

I knew from Susi’s intake paperwork that she is a very healthy and hard-working person. She was already helping to reduce her injury risk by not only running, but also cross-training with cycling and strength training. She’s a member of the local Fleet Feet running team, and had been working with a RunningLane coach. At the age of 25, she was ready to put knee pain behind her and look forward to enjoying many more years of competitive running. To help her do this, I performed a running assessment, which includes a video analysis of her running mechanics.

A running assessment appointment consists of four parts: discussion of the patient’s history and goals, screening examination, specific examination, and video analysis. Let’s look at what is involved with each of these, and what we found in Susi’s case:

Screening Examination

This is where I look at the person’s whole-body mechanics, make some general observations and discover clues that help me know what needs to be examined in more detail. By themselves these things are not necessarily problematic, but they give me an idea of where to look. In Susi’s case I saw that she stands with squinting patella; this means her kneecaps are looking in, towards the midline. Her foot arch is relatively neutral, her running shoes had an even wear pattern, and she didn’t note any discomfort with her shoes. She did well with prone planks, even with the addition of hip extension, telling me that she had reasonable gluteus maximus strength. However, she found side planks difficult, and could not do them with the addition of hip abduction. But the most eye-opening test was single-leg squats (SLS) – Susi had a lot of difficulty completing these with good form. She found it more difficult to maintain balance on the right side, but on both sides the knees dropped significantly into a valgus (knock knee) position, and her truck shifted. Similar was seen with lunges. All of this told me that Susi likely needed to strengthen and get better control of the gluteus medius muscles.

Specific Examination

Specific examination is where I dive in a little deeper to look more in-depth at specific areas of concern. Because they were the source of her pain, I knew that I needed to examine Susi’s knee joints. But the results of the screening exam also told me that her knee pain was likely being driven by mechanics in her hips. Susi generally had a good range of motion, but did have a slight loss of knee flexion mobility and a restricted range of motion in dorsiflexion of the ankle (toe/ankle coming up). She also had notably tight hip flexors, which considering that she worked in an office job with long sitting period, is not surprising! There was a notable weakness in the gluteus medius, which correlates with the squat and lunge findings. Otherwise there were no other remarkable restrictions in strength or mobility.

Running analysis

This is where it gets cool – my video capture equipment allows me to record a running from behind and the side, and play the video back in slow motion, to really break down their running mechanics and understand their bio-mechanics. I asked Susi to run about 10% shy of her current training pace on a flat treadmill. Looking from behind, I could see that she had a narrow gait pattern, and that each thigh fell inwards under loading (a little worse on the right). She also had a whipping motion on the right side, where it seemed like her toes whipped out after she had pushed back and the foot had come off the ground. This was likely in part due to the glut weakness, and also due to the lack of ankle mobility. She also had a fair amount of arm crossover to the midline. All of these motions were side-to-side, wasting energy that could have been used to propel Susi forward. Looking from the side, Susi landed with a slightly rigid knee on initial contact, but had relatively good hip extension. She tended to oscillate up and down 8-9cm; ideally I like to see 4-6cm, because higher numbers indicate excessive levels of loading and wasted energy.

Hypothesis

My next step was to put together all of this information to formulate a hypothesis about the cause of Susi’s persistent knee pain. My main concern was that Susi’s knees were falling in under loading, placing high stress on them and leading to high vertical oscillation. Narrow running stance also increases loading. All of this, combined with the fact that Susi’s pain limited her running distance, pointed to a load management issue. However, when there are issues with underlying bio-mechanics, it is very easy to overload without a great change in distance, time, speed, etc. So I knew that Susi’s rehab needed to focus on improving her mechanics first, and then expose her to more load in a controlled manner. I was also aware that because Susi had been struggling with this pain for so long, there would be a psychological component, and any flare-up would potentially set her back more than a runner who’d only been dealing with similar pain for a few months.

Treatment

To begin, I prescribed an exercise program consisting of five simple exercises, as well as two running cues to correct stride width and arm crossover. I also gave Susi guidance on what levels of pain were ok, and what needed to be avoided (see pain blog here!). Subsequently, Susi had four follow-up appointments over the next six months and periodically e-mailed to let me know how she was doing.

1st follow-up, 2 weeks later: Susi was doing well with the exercises, but still had soreness when running, as well as during climbs when cycling. I could tell she had improved glut strength and SLS mechanics. We increased the difficulty of her exercises, as well as added two new ones.

2nd follow-up, 4 weeks later: Susi had been able to increase her running and had only had two bouts of pain for ~30min each. In cycling, she was really feeling stronger and had set a century PR! She now had good SLS mechanics and was able to squat deeper than before. I looked at her jump-landing mechanics, and they showed that her knees were still falling in under the increased loading. To counter this, I added some plyometric exercise to her treatment – in this case, a jump-landing exercise. Plyometric exercises develop efficient storage and release of energy, rather than simply building strength. This is important, because building strength alone is not guaranteed to improve biomechanics like Susi’s.

3rd follow-up, 4 weeks later: Susi had run the Cotton Row 10k with no pain AND a course PR! She had also begun speed sessions with her running coach. We increased the difficulty of her exercises further, and added more advanced plyometric exercises.

Final follow-up, 3 months later: Six months after my initial evaluation of Susi, she was running pain-free up to 15 miles. She was having some achilles and hip soreness, but nothing consistent or concerning. We shot new video to compare to the original footage, and could see many improvements, including wider gait stance, less side-to-side and vertical motion, and less of the ‘whipping motion’ on her right foot. Importantly, her knees were no longer falling in with each step. She had lost a little hip extension, but we worked on it there on the treadmill and were able to correct it. She was still lacking a little in gluteal strength, which may have been because she had dropped off doing her exercises a little in the previous month. I gave her some final guidance for going forward to continue the strengthening and exposing her body to increased loading. We also discussed further refinements she can make to her technique, while recognizing that nobody has ‘perfect’ technique!

Having worked with Susi for six months, I was excited to see whether she would be able to run a pain-free marathon. In November she ran the Huntsville Half Marathon pain-free with a PR of 1:35:46. She and her running coach, Will Rodgers, decided to set a marathon goal race: the Snickers Marathon in Albany, GA, on March 5, 2016.

Bumps in the road?

After Susi’s final follow-up appointment, we kept in touch, and I was happy to hear that training for the marathon was going well. But about a week before the race, Susi scheduled an injury screening appointment with me because she had started having a little shin pain just before her taper week. My examination didn’t find anything that would prevent her from running the marathon, such as a stress fracture or major muscle tear. Instead, it seemed likely that she had developed shin splints, possibly due to her training schedule leading up to taper being slightly too aggressive. We reviewed the pain guidelines I had given her previously, so that she could feel confident about carrying on through the relatively low amount of pain she was experiencing (3/10).

It was exciting the next week to receive a message from Susi telling me that she had completed the Snickers Marathon in 3:29:35, with relatively even 8-min splits, and qualified for the Boston Marathon by ~6 minutes!Less than a year after her first appointment, she had succeeded in accomplishing one of her major goals!

Pace chart from the Snickers Marathon

Susi did have some more shin soreness after the race, as well as noticing some knee pain at mile 18 and 22, and felt that her knees were falling inwards towards the end of the race. We both felt that it was now time for her to see a doctor, for her peace of mind. The orthopedist diagnosed shin splints, and advised two weeks of relative rest.

What next?

Susi’s plan is to race Boston in 2017. Between then and now, she will be working to build up her body’s resilience to loading through a combination of continued technique improvements and building mileage. In a recent blog article, I discussed how research is showing that a high chronic workload helps protect the body from injury. This means that Susi can’t just take a long break and start training for Boston later this year without risking detraining increased injury risk. Instead, the safer path is to take a relative break, and then build back up her mileage gradually. Since she enjoys running, this hard work should not be a problem! Susi has been a fantastic, dedicated athlete to work with, and I wish her all the best for Boston 2017, and many years of enjoyable running after that!

Take-away:

If you’ve been struggling for a long time with pain that is holding you back from doing the things you love, I want to encourage you that it is possible to recover and move on. I specialize not in offering quick fixes that offer short-term relief, but in correcting the underlying biomechanics or training issues that are the root cause of the pain. Correcting these usually requires a commitment of time and energy from the patient, but can offer true and lasting relief that will set you free to pursue your goals, and not leave you dependent on ongoing passive treatments. So to close, here’s my version of a recent Facebook meme: