One of the most common complaints with runners is pain in the hips, pelvis area, or hamstrings, often just on one side.  These injuries can be frustrating because rest from running and some basic stretching and TLC to the area often does not resolve the problem.  The first step in managing these injuries is getting a clear bio-mechanical diagnosis, which mean not only identifying the pain source, but also pinpointing the root cause that is putting stress on that area.  Common medical diagnoses include:  hamstring strain / overuse; piriformis syndrome; SI or sacroiliac joint pain; and outer hip pain / tendinitis / bursitis.

As mentioned in previous Colorado Marathon articles, bio-mechanically, running is not unlike walking or crawling and there needs to be some degree of symmetry in the reciprocating motions through the hips, pelvis, ribcage, and torso. When your pelvis is slightly twisted, or range of motion in the hips is asymmetrical, the neuromuscular system is forced into a compensatory mode to simply stabilize the body against the forces of gravity, and to generate forward motion. For those experiencing one of the above listed pain issues, a good physical therapist should be able to work through the following “flow chart” of clinical decision making to resolve the problem.

1. Is there a pelvic asymmetry that results in loss of hip range of motion?
2. How is your ability to isolate key pelvic/hip/core stabilizing muscles with isometric manual muscle testing? These tests give insight into how well you are recruiting key muscles during the dynamic activity of running.
3. Almost all running injuries present with altered muscle recruitment patterns (which can lead to weakness), habituated through hundreds of miles of running. In coming years you will hear more and more about the neurological aspect of muscle firing patterns, and you will hear less and less about the approach of just stretching whatever is tight.

Here are some things you can look for on yourself that could indicate a bio-mechanical imbalance. Remember, these things may not produce an injury until your overall mileage or long runs increase and the imbalance gets “exposed”.

Standing posture: Do you tend to stand predominantly on your right leg with the right hip kicked out to the side; much more so than standing on the left?

Driving posture: Do you notice that when driving, your left leg is constantly splayed out and resting on the car door?

Lying posture: When lying on your back with legs completely relaxed do you notice that one foot/leg is more turned out than the other?

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Overuse injuries are the most common reason for runners to have to alter their training or pull out of races. Certainly, errors in running form, shoes and training / mileage intensity contribute to these injuries; however there is also a bio-mechanical aspect to many of these problems.

A concept that is gradually being embraced more in sports medicine is muscle firing patterns. As with any physical activity or motion there are key, or primary, muscles involved for stability or propulsion     during running gait. These muscles play a different role than the “secondary” or back up muscles for  running. Recent studies have shown that runners who are experiencing pain (knee pain, IT band syndrome, hamstring pain, foot pain, and hip pain) often have altered recruitment patterns when utilizing lower body muscles.

Running requires a reciprocating motion of the legs, pelvis, and torso not unlike crawling or walking.    Although not absolutely required, more symmetry is better than less to perform an efficient running gait, especially at longer distances. Problems occur when primary running muscles fatigue too early or fail to be recruited efficiently. Our neuromuscular systems are trained to keep us moving down the road, whether 3 miles or 19, and the body, being the ultimate compensator will recruit whatever it needs to finish the workout. Interestingly, most runners with biomechanical imbalances then begin to experience tightness or pain in other areas as they compensate for primary muscles that have gone on a “labor strike”. Those secondary or back-up muscles that then become overused often become tight, and the mistake is to simply “stretch whatever is tight”, when really what is needed is to get the primary muscles firing efficiently and to have appropriate strength endurance such that they do not quit during a run.

Once key running muscles start into a compensatory recruitment pattern (some working too much,    others working too little), the very nature of running tends to habituate the process and create an       altered “muscle memory” pattern that affects the runner’s ability to control alignment, stability,           pronation/supination and simply how efficiently they are moving down the road.

The “efficiency” of running is further altered when there is an asymmetry of pelvis-hip alignment or range of motion. Many times a runner may have such an asymmetry, but be able to run pain free when their weekly mileage is lower, but when they attempt to increase overall mileage or long runs the imbalances are exposed and they develop one of the overuse syndromes.

Testing for these running imbalances is quite easy and usually quite an eye-opener for the athlete.  Simple corrective exercises focused on proprioceptive muscle recruitment patters (turn off the overused muscles and recruit/activate/strengthen the slacker muscles), or balancing out the hips/pelvis, usually results in major improvements in not only pain but running efficiency. You’ll know when you are a candidate for such intervention when rest, altered training, and simple stretching do not handle your problem.

If you have a specific problem or question related to an overuse running injury, send us an e-mail and we can help play detective and uncover the root causes of your issue. Happy Running!

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Our topic last month regarding foot and ankle pain discussed the importance of understanding the link between mechanics at the foot and what is occurring at the knees, hips and core.  Runners frequently experience anterior knee pain, commonly referred to as patellofemoral syndrome (PFS), or IT band pain.  In both diagnoses it is common to experience pain with squatting, climbing stairs, simply raising from a chair, and of course with running.  IT band pain tends to be the lateral / outside of the knee, while PFS pain is more under the kneecap or generalized to the front of the knee.

Mild cases of knee pain typically respond quickly to rest or modified training, stretching and icing    however when symptoms persist it is important to consider that muscle strength imbalances may exist. If so, rest and stretching alone will not correct the underlying biomechanical strength problem. Two quick tests that may shed some light on your strength and stability are:

Single Leg Sit to Stand

Sit on the front edge of a chair with one foot lifted up off the ground. Without using your hands, rise from sitting up to standing, and then slowly back down while noting the amount of effort right vs. left. Also note whether one knee tends to turn or dive inward as you perform this test. If this seems easy and symmetrical, then move to a shorter chair or to a coffee table and repeat.

Single Leg Stance with Opposite Leg Swing

Stand on one leg, ideally in front of a mirror. While maintaining balance, level shoulders and hips, swing your opposite leg side to side in front of your stance leg. Attempt to keep a continuous motion with the swinging leg and perform up to 20 reps while noting your ability to balance on the single leg and how stable your torso is.

Both of these functional tests often reveal that on the side of knee pain there is a lack of strength or overall stability. More detailed testing with a physical therapist typically uncovers poor strength in     several key running muscles that have an important role in maintaining proper alignment of the knee during shock absorption phase (footstrike to mid-stance), and during propulsion phase (mid-stance to push-off). A lack of strength results in a compensatory knee position in which the kneecap gets pulled away from its normal alignment or the IT band as it crosses the outer knee gets forcefully strained.

Several recent scientific studies (Journal of Orthopedic and Sports Physical Therapy) have indicated that strength and proper muscle firing patterns in the hip muscles (gluteus medius, gluteus maximus) have a significant role in controlling knee alignment and the biomechanics at the knee. Both of these muscles are at work with the above two tests, so a significant asymmetry may indicate that you have weakness in these important running muscles.

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