Running tips: one foot in front of the other

1. Running tips: one foot in front of the other Biomechanical Gait and Running analysis Kurt Gengenbacher, PT, DPT, CSCS

2. History • Patient presents for one time treat/running evaluation (End of August 2010) • Drove 3 hours for this one time visit • Chief Complaint – Right lateral knee pain • Similar symptoms in Left knee May 2009

3. Question #1: Which gait abnormality is associated with a self-protective mechanism related to injury in the LE? • Ataxic • Trendelenburg • Antalgic • Steppage

4. What other subjective information would you like?

5. Past medical history • 1999/2000 MCL tear Left knee while skiing • non-operative management with PT (resolved) • 2001 – onset of Right hip pain with distances > 10 miles • Sx’s in PSIS, lumbosacral region, hip, but not past gluteal line • Cessation of running due to pain • August 2008 – same Right hip pain returned with training for half marathon • PT treatment for posterior capsular tightness • Resolution by end of the year, ran Philly half marathon without sx’s • January 2009 – occasional hip pain when training for full marathon • Onset at 15-20 miles • Ran the NJ marathon in May 2009 • May 2009 – treated for chronic LBP, and independent management of Left lateral knee pain • LBP managed with core exercises • Knee pain resolved with ice, rest, and decreased mileage for ~3 weeks

6. Further Information About Current Injury • Onset – October of 2009 during a 20 mile run • Running necessary mileage for marathon training, but with pain during any runs > than 10 miles • With independent fibular manipulation he is able to complete work outs without symptoms • Previous PT for Right knee (October-December 2009) – focused on reducing ITB restrictions and hypomobility in proximal tib-fib joint with symptom resolution and return to “easy runs” • Orthotics used from October 2008 – March 2010 • Pt noted no change in symptoms when he stopped using orthotics

7. Other Subjective Information • No limitations at work/home • No diagnostics • Current Medications – Prednisone and Lipitor • Goals • Run in Chicago or Philly marathon to qualify for Boston • Improve stride economy and prevent injury

8. Question #2: To avoid/assess for side effects related to long term prednisone use, pt’s should be instructed to do all the following, except: • Have a regular blood test • Immediately stop use if taken for 1 month or more • Get DEXA-scan occasionally • All of the above

9. What do you want to measure and assess?

10. Objective Measures

11. Running Gait AnalysisWhat aspects of running gait do you want to look at during your observation?

12. ROM • Hip RL • IR 33° 33° • ER 44 ° 52 ° • ABD 26 ° 27 ° • EXT 15 ° 12 ° • Knee • Flex 147 ° 144 ° • Ext lack 2° hyper 3 ° • (right passive hyper 2°) • Ankle dorsiflex 5 ° 11 °

13. ROM • Hip RL • IR 33° 33° • ER 44 ° 52 ° • ABD 26 ° 27 ° • EXT 15 ° 12 ° • Knee • Flex 147 ° 144 ° • Ext lack 2 ° hyper 3 ° • (right passive hyper 2°) • Ankle dorsiflex5 °11 °

14. Strength (with HHD) RLStrength Index • Hip IR 19.4# 15.3# 127% • Hip ER 24.0# 21.0# 114% • Hip ABD 21.9# 22.0# 99% • Hip ext 10.0# 15.0# 67%

15. Strength (with HHD) RLStrength Index • Hip IR 19.4# 15.3# 127% • Hip ER 24.0# 21.0# 114% • Hip ABD 21.9# 22.0# 99% • Hip ext 10.0# 15.0# 67%

16. Joint Mobility & Palpation • Proximal and Distal Tib-fib: • Right hypomobile anterior and posterior • Left normal • Patella • Right hypomobile superior, inferior, and medial • Left normal • Talocrural • Right hypomobile posterior • Leftnormal • Palpation: (+) TTP over distal ITB and fibular head

17. Anthropometric & Flexibility Measures • Anthropometric Measures • Leg Length • R: 90 cm, L 90 cm • Q angle • R: 10, L 3 • Flexibility • Prone Quad (heel to buttock) • 20 cm B • HS (90/90) • R lack 44, L lack 42 • Ober’s (from table) • R 15 cm, L 14 cm

18. Observation • Standing posture • Left calcaneal eversion and toeing out • Right neutral calcaneal alignment • Single limb squat • Left slight pronation, genu valgum at end range • Right moderate pronation, genu valgum throughout range

19. Gait Analysis • Walking, barefoot • Left toe out and excessive pronation through heel strike into mid stance • Right slight supination at heel strike and maintained through stance • Too many toes sign positive bilateral • L 5 toes • R 4 toes

20. Question #3: What muscle is likely weak in a patient with positive too many toes sign? • Flexor hallucislongus • Peroneus longus • Anterior tibialis • Posterior tibialis

21. Question #4: During the Initial Contact phase of the gait cycle the: • Pelvis is rotated back, the hip is flexed, the knee is flexed, and the ankle is plantar flexed • Pelvis is rotated forward, the hip is extended, the knee is fully extended and the ankle is dorsiflexed • Pelvis is rotated forward, the hip is flexed, the knee is fully extended and the ankle is in neutral • Pelvis is rotated back, the hip is flexed, the knee is fully extended and the ankle is dorsiflexed

22. Video #1: Lateral View Running Gait

23. Video #2: Posterior View Running Gait

24. What did you see?

25. Question #5: During running gait, the subtalar joint everts ~10 degrees from footstrike to midstance. The primary muscle action occurring is: • Eccentric peroneus longus • Eccentric posterior tibialis • Concentric peroneus longus • Concentric posterior tibialis

26. What impairments would you want to address?

27. Assessment • Pt has decreased R knee ext and dorsiflex ROM which are contributing to alterations in his gait with running, leading to pt’s c/o lateral knee pain • Pt is unable to achieve TKE on the right at landing which causes a functional leg length deficit and forefoot strike • Pt’stalocrural and patellofemoral joint mobility are decreased and may need treatment (joint mobilization) if stretching does not provide significant ROM gains • Ptneeds neuromuscular re-education during running to control femoral position with activity (genu valgum in stance and compensations in running); This dysfunction is also contributing to his increased lateral loading on the right

28. How/why will your treatment plan be different for this patient versus a typical patient?

29. Performing independent HEP: ADVICE! • Prioritize your information • Pt’susually have poor compliance with HEP, so sell the must haves • Work stretching program into running schedule • Stretch before and after run • Patellar mobilizations • After stretches • Sitting at a red light • Before you get up to get something out of the fridge • Hip strengthening • During commercial break • Before bed • On off day from running do them twice

30. HEP: ROM • Need to work on stretching to increase knee and ankle ROM • Self patella mobilizations to also improve knee ROM

31. HEP: Hip Strengthening

32. HEP: Neuromuscular control /Running Re-training • Focus on foot and knee position with landing • Decrease forefoot abd and genu valgum • Concentrate on firing glut at landing to help control foot and knee position • Need visual cueing early (mirror and treadmill) • Gait retraining protocol: Gradual change in form/technique • Week 1 – all done with visual feedback • Start with 15 min and end at 24 min • Week 2 – gradually take away visual feedback • Start with 27 min total and 21 min with feedback • End with 30 min total and 3 min with feedback

33. Questions?