Running is a wildly popular sport. It is a great form of exercise for both body and mind and it can be done almost anywhere – all you need is a pair of sneakers. As a runner myself, I am a big advocate for the sport. The mass running addiction that has developed over the past several years is awesome.

We all know that runners can be tricky patients. We can do everything right with them – strength training, stretching, foam rolling and so on – but they still don’t get better. What gives?

We haven’t watched them run! What our injured runners really need is gait retraining.

The running assessment

A running assessment is a simple, yet highly informative component of a runner’s evaluation. While a standard PT assessment is still indicated for a running patient, I cannot emphasize the running portion enough. All you need are a treadmill and a smartphone with a video camera. There is more advanced technology that you can use, such as Dartfish or Spark Motion, but a simple phone camera will do the trick if these applications are not available to you.

Next time you have a runner come into your clinic, have them hop on the treadmill for three to five minutes and take a video in the slow motion setting. While three to five minutes will only capture a limited portion of your patient’s running form, it is enough time to identify red flags in the majority of runners.

Your next step is to review the video with the patient. I can tell you from personal experience that runners appreciate this. It is helpful for them to see what they look like running. The individualized approach makes it more likely that they will remember your advice and also buy into your treatment plan. Just make sure to avoid PT verbiage in your explanation to the patient (i.e. dynamic knee valgus, pelvic drop etc.)

Running form evaluation

Since we don’t always have much time in the clinic, I have broken down runners into two categories: overstriders and medial collapsers. This is admittedly a slight oversimplification, but these categories will capture most of what you will see in the clinic and will help streamline the evaluation process. However, please note that everyone is different so your patient may exhibit varying combinations of what is listed below.

Overstriders

The first category of runners consists of overstriders. Overstriding can be picked up when reviewing the video taken in the sagittal plane. Like the name says, overstriding simply means that a runner exhibits a long stride length and therefore takes fewer steps per minute for any given distance.

These injuries often result from excessive impact forces at the hip, knee and ankle joints, which accompany overstriding.

When examining video in the sagittal plane, there are several key elements that will alert you to overstriding. These include any combination of the following

• Increased vertical displacement
• Decreased knee flexion angle at initial contact
• Increased dorsiflexion contact angle
• Foot placement far ahead of the center of mass

Below is an example of an overstrider. In this photo you can clearly see that upon initial contact, the knee is almost fully extended and the foot exhibits a large dorsiflexion angle.

Runners who present with overstriding will benefit from gait retraining that targets shortening stride length and increasing step rate. By simply taking more steps and therefore decreasing their stride length, runners will decrease impact forces and improve their chances of injury recovery and future injury prevention.

Medial collapsers

The second category of runners is made up of the medial collapsers. Medial collapse is observed in the posterior frontal plane. If your runner is a medial collapser, you will notice that he or she fails to keep the body level during the stance phase. This is typically due to failure to activate key muscle groups such as the glutes and the core during running. Medial collapse is associated with common running injuries including, patellofemoral pain syndrome, iliotibial band syndrome and stress fractures.

A medial collapse can manifest during the right and/or left stance phases. Medial collapsers will exhibit any or all of the following:

• Contralateral pelvic drop
• Increased hip adduction angle
• Ipsilateral trunk lean
• Dynamic knee valgus
• Crossover gait

Below is an example of a medial collapser. In the photo you can see a considerable pelvic drop during right stance time. Also, while dynamic valgus is not quite as pronounced, there is decreased distance between the knees as the patient collapses medially when accepting weight.

Runners who demonstrate medial collapse will also benefit from gait retraining. While it is true that most of these runners will also require a strengthening program, gait retraining will ensure that the exercise interventions carry over to running.

Gait retraining for faulty running form

Strengthening is not enough to correct faulty running form.

Strengthening activates different areas of the motor cortex than skill re-training does. Additionally, skill training results in cortical reorganization, whereas strength training does not. This essentially means that the brain perceives strength training and skill training differently. Yes, our patients may exhibit weakness, but we must respect that running is a skill. Strengthening alone has proven to be ineffective in modifying faulty running gait. Gait retraining, on the other hand, will enhance a runner’s form and thus reduce risk of future injury.

Step rate gait retraining

To understand how to best retrain a runner’s gait, let’s go back to our two categories of runners with faulty mechanics: overstriders and medial collapsers.

Overstriders will benefit from step rate retraining. If they learn to increase their step rate, their stride will shorten and the resultant impact forces will decrease. There is no magic number for step rate – it simply has to be higher than the runner’s originally preferred step rate. Increases as little as 5% have been shown to reduce joint compressive forces and decrease risk of injury. This alteration in running mechanics has proven to be just as, if not more important, than a strengthening program.

To determine step rate, count the patient’s number of right foot strikes over a 30 second period. Multiply this number by 4 to determine steps per minute (AKA step rate). This will provide you with a baseline rate from which to increase 5-10%.

There are several ways that we can help a runner increase step rate. Runners can use a metronome app to match their steps to a desired step rate, but they can also use their playlist to achieve this.

Without being instructed to run to the beat, runners demonstrate increases in self-selected step rate when music tempo is faster. To find the right music there are metronome resources, such as JogTunes that will find music according to BPM (beats per minute) to match your patient’s desired step rate. If a runner prefers to run with a traditional metronome, there are countless apps available for that as well.

Visual retraining

Medial collapsers will benefit from visual retraining. Many of us use a mirror in the clinic for exercises, but we can use it for gait retraining too. Using a mirror for visual retraining has been shown to be an effective method of biofeedback for improving running form.

The easiest way to create a setting for visual retraining is by placing a full length mirror in front of the treadmill. Your patient should already be familiar with their presentation of medial collapse so your only job now is to alert them to key correction points. For example, if dynamic valgus is the major problem, simply tell the patient to “increase the distance between the knees”. When runners can see their knees in the mirror they are more likely to self-correct and subsequently remember the new movement pattern. The same method can be used to help the runner maintain a level pelvis. A simple cue to “keep the hips level” will help retrain the runner. I have also found that placing tape on a patient’s hip bones is is a helpful way to enhance visual feedback in this scenario.

Be a movement expert

While gait retraining is a key component of running rehabilitation, I am in no way advocating for the total abandonment of a strengthening program. Most runners will benefit from strengthening. However, if we only utilize strengthening and flexibility interventions then we have not maximized our potential as physical therapists. No one understands movement better than we do. It is our job to reshape movement in order to help our patients achieve long term recovery and optimal performance.

References

Brough C, Colón W. Introduction to Current Concepts in Clinical Management of the Running Athlete: An Evidence Led Approach. Columbia University Medical Center. April 2, 2015.

Heiderscheit BC, Chumanov ES, Michalski MP, et al. Effects of Step Rate Manipulation on Joint Mechanics during Running. Medicine & Science in Sports & Exercise 2011;43(2):296-302.

Influence of Stride Frequency and Length on Running Mechanics: A Systematic ReviewSports Health: A Multidisciplinary Approach 2014;6:3 210-217

Schubert AG, Kempf J, Heiderscheit BC. Influence of Stride Frequency and Length on Running Mechanics: A Systematic ReviewSports Health: A Multidisciplinary Approach. Sports Health. 2014 May;6(3):210-7.

Van Dyck E, Moens B, Buhmann J, et al. Spontaneous Entrainment of Running Cadence to Music Tempo. Sports Med Open. 2015;1(1):15

Willy, R.W., Davis, I.S., 2011. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther 41, 625-632.

Willy RW, Buchenic L, Rogacki K, et al. The effects of a gait retraining program using mobile biofeedback in high risk runners. Proceedings of the 3rd International Patellofemoral Pain Retreat 2013.

Willy RW, Davis IS. Varied response to mirror gait retraining of gluteus medius control, hip kinematics, pain, and function in 2 female runners with patellofemoral pain. J Orthop Sports Phys Ther 2013;43(12):864-74.

Wouters, I., Almonroeder, T., Dejarlais, B., Laack, A., Willson, J.D., Kernozek, T.W., 2012. Effects of a movement training program on hip and knee joint frontal plane running mechanics. Int J Sports Phys Ther 7, 637-646.