Happy Hips

As you likely know, the hip is a huge ball and socket joint that is relatively stable and yet maintains a fair amount of joint range of motion.  Because running is a repetitive motion which requires that our lower limbs bear 2.5X our body weight each step, the hips take a great deal of load in any amount of distance we run.  What's helpful to know is that strength is only one component of well-functioning hips.  Many people rightly attempt to strengthen the muscles surrounding the hip joint but what they may neglect are exercises which train their hip control and stability.  This is especially important for runners as we are essentially hopping from one foot to another.  If you have poor coordination and balance on one leg, you cannot control loads very well when you're running.  Symptoms of poor hip control can manifest in lower extremity injuries or areas of chronic stiffness (i.e. tight regardless how much you stretch).

So without further ado, give these exercises a try in your running routine for a few weeks and see if you find your stride feeling smoother and your body less sore overall.  I typically do a few of these exercises pre/post run and will sometimes do longer sessions on days that I do not run.  Shoot for 3 sets of 10-15 repetitions for the first 3 exercises and 5 rounds for each leg on the Star Reaches.  Finally, using a mirror or other visual feedback may also help ensure your form is correct.

1. Hip Drops

Start on a step with a level pelvis, keep both knees straight during the entire exercise.  Lower your leg SLOWLY by pushing the hip of your stance leg out to the side.  This will cause your pelvis to drop on one side.  Avoid leaning your torso.  Raise your pelvis back to the starting position using the hip of your stance leg.  You should feel the work mostly in the side of the hip of the leg you're standing on.

Starting position with a level pelvis.

In this case I am pushing my right hip laterally to the side to drop the left side of my pelvis.
Keep both knees straight and make sure to control both the lowering portion and the returning to a level pelvis.

2. Single Leg Balance with Hip Flexion

In this exercise you are simply flexing one hip to 90 degrees while maintaining good balance and control.  You can use a resistance band to increase the difficulty.  Keep your torso upright during this entire exercise.

Starting position

Finish position.
Keep your balance and a tall spine!

3. Single Leg Romanian Deadlifts

Stand on one leg with a slight bend in the knee.  The goal of this exercise is to bend forward from the hip as much as possible without moving the spine.  Keep your spine straight during the entire exercise, your back leg should remain extended in line with your spine.  To bend forward, push your hip back until you feel a good stretch in your glute muscle.  Once the hip stops bending, return to the starting position using your hip (not extending with your back).

Starting position.

Finish position.
Keep your spine locked with your back leg so that everything is in a straight line.
Bend through your hip as much as possible while keeping the spine elongated
(i.e. this works your hip hinge).

4. Star Reaches

Again stand on one leg with a slight bend in the knee with 8-markers placed in a circle around you.  The goal of this exercise is to bend from the hip as much as possible as you reach for each of the markers.  Reach each marker separately by returning to the start position before reaching for another marker.  This will challenge your balance and your hip control more effectively.

Forward reaching.

Side reaching.

Contralateral posterior reach.

Bend So You Don't Break

Truth be told, I’m getting excited for sandal season to start again.  I am solidifying my race calendar and I am planning to cap the year with the Leadville 100-mile trail run and maybe even another Spartan World Championship.  As each of us look to our summer and fall running seasons I wanted to share one of the best and most simple form fixes you can implement now to give you a more successful season.

One of the most common mistake runners make in their form is to over-stride.  Over-striding can be defined as any form of landing that causes a braking force.  One of the easiest cues to help remedy this situation is to simply “bend your knees more.”  In theory, when we are running we are using our legs as giant springs.  If our knees are not flexed enough during running gait we are more likely to land with the foot too forward of our center of mass.  This forward foot landing creates a brake and diminishes our forward momentum.  This braking effect leads to higher impact forces and reduces our running economy.

Need a good example of the difference bending your knees can make?  Compare yourself running up a steep hill versus down the same hill.  Because it takes excessive effort to over-striding while running uphill, most people don’t do it.  They instead bend their knees more and take shorter steps.  On the other hand, over-striding is very common while running downhill.  Film yourself running downhill, then repeat with your knees bent deeper.  You should see a smoother decent with your knees bent more (i.e. less bobbing up and down).  Combine this with an increased cadence and the results should be less achy hips and knees.

In addition to bending the knees and allowing your leg springs to work, I also like to focus on relaxing my calf muscles and the tops of my feet.  Bending your knees more should help to relax your calves naturally but if you’re used to holding excess tension in your calves and feet, you might want to cue yourself to relax further.  Many runners who over-stride will also demonstrate increased vertical oscillation (i.e. bobbing up and down).  Following the aforementioned cues can improve your efficiency and likely allow you to train more miles and a faster pace due to less impact forces.

Bending the knees helps you land with your foot closer to your center of mass.

Filming your gait can be your best tool because sometimes what we think we are doing is not what we are actually doing.  I often use film for my runners so that they can compare how different cues change their gait.  When we see improved efficiency and when the runner feels smoother and more comfortable, we know that we’ve found the right cue.  I have found over the years that “bend the knees more” has been one of the best cues to reduce impact forces and smooth out gait.  This is especially true for downhill running when runners are most likely to over-stride.  Experimentation is the foundation of learning so it’s up to you to give these cues a try and see how your body responds.

Best wishes for a happy and healthy running season!

Firefighter Success Story

My apologies for the lack of NPR posts as of late.  I joke with my friends and family that I have about 5 jobs (things I get paid to do), and like most of you, a dozen or more regular roles I play.  Still I really am quite passionate about sharing good information (and stories) when I can get around to it and today is one of those glorious days.

As you all know, I have been obsessed with feet and their function since I made my own transition to barefoot running (and more minimal shoes/sandals).  In my own transition, I was quite horrified to realize just how damaging the myths of footwear have been to both myself and most in our modern society.  This along with running form and training methodology are perhaps my favorite topics of discussion (at least in the rehab and performance world).  I also love everything related to the outdoors, coffee, and building things.

So without further adieu, I wanted to share this success story from a fireman who lives in the Nashville area and reached out to me last summer through our mutual friend.  I'll start from the beginning when "Q" contacted us through our website...

Hello,

I am a paramedic and a firefighter and I watched some of your YouTube videos that a mutual friend (JP) showed me for feet exercises. I looked up your website from the video and saw that y'all offer a discount for first responders. I just wanted to say thank you and let you know it is much appreciated. If I didn't live in the Nashville area I would probably be a client, but I just wanted to say thanks for the information and offering us a discount!

I replied with a few additional resources.  "Q"s personal story is more in-depth on his next email response.

JP actually showed me some of your YouTube videos and I found your blog after that. I developed plantar fasciitis over two years ago. It was mostly from jogging hours on end barefooted with my daughter that had colic (it was the only way to get her to not cry) and heavy turnout gear for work. I went to the podiatrist and she said I had "really flat feet" and said I pretty much just had to live with it, wear orthotics, and never go bearfooted again.  I have pretty much completely quit running and changed my whole PT (training not therapy) regime to cope with it. While the plantar fasciitis has gotten better, my feet over all are weaker and ache more than they used to. I started reading more stuff and came to the crazy hypothesis that through PT I could strengthen my feet and even maybe not be flat footed anymore. I was asking JP's input on my theory and that's when she pointed me in your direction. For the first time in a couple years I feel like there is hope and I won't be hobbled and decrepit! I know that might sound a little melodramatic, but as much time and money as I have wasted trying to find the right insoles, shoes, orthotics, and so on with no real solution, maybe it's not. I am just amazed that someone can have a doctorate in feet and be so terrible at feet (in reference to the podiatrist I went to, and have had friends/coworkers with similar experiences). That's why I wanted to email y'all and say thanks for putting so much good and free information out there! I started doing exercises almost a week ago and already have noticed an improvement. Tomorrow when I am on shift, I will start to implement the stuff from your blog.

I hadn't heard from "Q" since last July until yesterday when I received this email.

Hey Sam, it’s been a while since I emailed you. I am JP's friend that is a firefighter that had flat feet. I just got done with my annual work physical and my doctor (former Brigadier General for the Army) called me a “dumb shit.” I was honored! I figure after a full military career and 49 years as a MD, doing something to illicit being a “dumb shit” from a Church of Christ, retired General was quite a feat! 

We got to the interview portion of the physical and he asked about my flat feet. I wore shoes today to avoid having to explain myself, but it didn’t work. I told him I had been working on them. He asked what that meant. I told him I have been doing a lot of physical therapy exercises and running barefoot and that I have got to where I can run a mile with no problems. It was at this point he sat straight up in his chair and called me a dumb shit. I took my shoes off and showed him my feet. He starred at them, stuck a finger under my arch and said, “You have arches! I guess we will take that off your record. So how does one go about rebuilding their arches?” I demonstrated several exercises and explained my position on feet have been weakened by shoes and are not allowed to function as designed. He didn’t buy it and I did not convert him, but he could not argue with my arches. 

I showed him a YouTube video showing the natural versus shod running forms and the differences of impacts on pressure plates and he said I was still a dumb shit but he did hear me out. I figured you would get a kick out of it, but also hope it’s encouraging! Thanks for putting your blog and videos up, because I was feeling kind of hopeless and doomed to a life of hobbeling around and not running and playing with my kids before I started the transition. Thanks for the help and I hope you enjoyed the story!!! 

Thanks! Q
PS I have gotten up to running 1 mile barefoot in the grass with no problems!!! 

Wait what?! You strengthened your arches???

Right medial arch before strengthening

Right medial arch after strengthening

Left arch before strengthening

Left arch after strengthening

The email from "Q" highlights a great story of self-discovery, discipline, tenacity, learning, and growth.  I believed many of those same myths prior to my experimentation and once you're on the other side you begin to realize how many beliefs turn out to be ridiculous and very limiting.  I've stated many times that permanently casting/bracing the feet makes no more sense than doing the same to any other body part.  I previously highlighted Barefoot Matt's story which is quite similar.  Having bunions and imperfect feet myself, I resist the idea that one's foot has to look like the ideal in order to go barefoot.  What we need are strong and flexible feet, good reflexes, and muscles/tendons that have undergone smart training.  No one preaches that everyone with scoliosis should avoid loading the spine for the rest of their lives because it's not perfectly balanced.  I hope you raise an eyebrow when someone suggests that permanently limiting the use of a body part is the answer to your injury or mal-alignment issue.  As a therapist I can only say, welcome to the mal-alignment club...now let's learn to move better.

Treating Injuries:

Are Rest, Ice, Compression, and Elevation Appropriate?

“Coaches have used my “RICE” guideline for decades, but now it appears that both Ice and complete Rest may delay healing, instead of helping.”

 – Gabe Mirkin, MD, March 2014

Dr. Mirkin first used the term Rest, Ice, Compression and Elevation (RICE) in 1978.  In the years that followed RICE became recognized as the standard of care for acute injuries (especially for the ankle).  RICE was actually later modified to Range of motion, Ice, Compression, and Elevation to reflect the need for movement after an injury.  Today, the original developer of the RICE protocol, Dr. Mirkin, now believes that both ice and rest may actually delay healing.  Inflammation is the body’s natural response to injury and brings in important healing factors.  By applying ice and compression early, we may inhibit swelling but this also inhibits the body bringing in important cells to begin the healing process.  Attempting to inhibit swelling early on may actually delay healing.  Additionally, Dr. Mirkin has found that “Anything that reduces your immune response will also delay muscle healing, such as cortisone-type drugs, pain-relieving medicines like NSAIDS, immune-suppressants, and applying cold packs or ice.” 

So what is the answer?

Reducing an athlete’s symptoms requires load management.  Isometric (holding against resistance while not moving) contractions have been shown to be analgesic and pain reducing.  It is important to factor in stage of tendinopathy and treat it as part of a well-rounded rehabilitation program involving kinetic chain exercises, education in proper landing technique, and management of load and return to sports.   Additionally, children heal faster and require little external help except management of pain and loading for short periods of time.

Recommendation

Avoid ice, NSAIDs, or other corticosteroids early on.  A short bout of 3-5 minutes of ice may be appropriate for pain management to allow the athlete to movement and begin load management as soon as possible.

Rudavsky A, Cook J. Physiotherapy management of patellar tendinopathy (jumper’s knee). Journal of Physiotherapy. 2014.  60: 122–129.

Contact us at www.naturalperformancerehab.com for any questions

15 Health Benefits of "Barefoot" Running Shoes, According to Science

Wanted to share this article on barefoot living and using minimal shoes from another great experimenter.  This is one of those life lessons I keep learning over and over again.  Be flexible, adaptable, open, willing to try new things and experience new paradigms.  Ultimately we have to be our own experimenters, despite whatever the latest study might suggest is correct, the answer is what works best for us.

15 Health Benefits of Barefoot Running Shoes, According to Science (+8 Tips for Beginners)

Common Causes of Knee Pain when Running

A common myth we have all heard floating around at one time or another is that running will "ruin your knees."  This is even stated by some well-meaning medical practitioners despite the lack of scientific evidence.  In fact, studies suggest that if anything, runners are less likely to develop debilitating hip or knee osteoarthritis when compared to a more sedentary population (ref 1 & 2).

That said, many runners do suffer with knee pain at some point in their running careers.  This month I hope to direct your attention to a few common causes of knee pain and broadly discuss their remedies.  Let me preface the rest of this article by saying for most knee pain caused by activity, the official diagnosis isn’t particularly helpful.  It’s the medical version of Juliet’s monologue on the balcony, “what’s in a name?” she says!  Whether you have tendonitis, tendonosis, a partial tear of something, iliotibial band syndrome, or you ate too much cake last night…the key in recovering is finding the dysfunction.

Problem #1 - Hip and/or ankle stiffness

The ball and socket joint of our hips provide our lower extremities with a great deal of motion and adaptability.  Likewise, our feet and ankles are paramount in adapting to our running surface.  If either of these areas lack proper range of motion, it's not uncommon for this imbalance to manifest itself as knee pain.  Because the hips and/or foot/ankle complex is not moving correctly, the knee will take excess stress.  Your practitioner should always check your hip, ankle, and foot for restrictions if you present to them with knee pain.  Once you understand the problem, the remedy is quite intuitive, improve range of motion and practice basic exercises to ensure the muscles of the hip, ankle, and foot are working properly.

Problem #2 - A lack of pelvic and core control

This problem is a bit more insidious and often more difficult to self-test.  Essentially, many of us have muscle imbalances involving our spines and pelvis.  Some of these imbalances may occur because we sit too much or we over-train one movement or activity.  Most adults do not move in novel ways unless they are actively engaged in a movement practice or have a job that requires many different types of activities (i.e. When was the last time you did a cart-wheel?).

Ultimately, the muscles throughout our trunk (core) must coordinate with the muscles in our hips to provide a stable pelvis when running.  If we are not coordinating things correctly we may find that we have chronic back, hip, knee, or even ankle/foot pain.  The coordination process is quite complicated but thankfully the remedy is usually much more simple.  In the same way that one learns to throw a baseball or play the violin, we can break down the basic movements of the spine and pelvis, testing each one until we find a lack of integrity.

On slow motion analysis, a lack of pelvic or core control can manifest itself in a loss of alignment in the spine, pelvis, knees, and the ankle/foot.  It is usually most evident in the mid-stance phase, when all of the body weight is rested on a single leg.  It is at this point we usually see a break down of control.

If my pelvis dramatically loses alignment (drops in mid-stance), my entire lower extremity and spine will have to compensate.  Here we see a mostly level pelvis which allows the knee to stay aligned between the hip and foot.

On the other hand, a hip drop will cause compensation somewhere else in the body.  This gentleman is leaning his trunk to maintain balance and may also be increasing injury in the lower extremity.  Notice his left foot (behind him) is crossing towards the right leg which further identifies the hip drop.

Problem #3 - A lack of foot control

In our world of overly-cushioned shoes and high-priced orthotics, most runners today lack proper foot function.  It is a self-fulfilling prophecy to say that people need motion control shoes because they have never learned to control their own foot motion.  On slow-motion running gait analysis, the same pitfalls seen with poor pelvic control can be caused by a lack of foot control.  In fact, unless a practitioner tests both areas, they won't know which is causing the problem.  Often it is best to treat control and coordination issues globally because we know that everything has to work together to produce a healthy running gait.

Problem #4 - Over-striding or slow cadence

I have discussed this topic in the past but suffice to say over-striding or running with a slow cadence (<160 steps-per-minute) is highly associated with more impact force through the lower extremity.  Greater impact forces are associated with more lower extremity injuries to include knee pain.  Strength training and plyometric drills can help to improve force output, meaning, it is easier for us to run and maintain a healthier, more efficient cadence.  Poor force output resembles the ultra-shuffle while a high-force output can be seen in sprinters and excellent long-distance runners (Eliud Kipchoge anyone?).

Over-striding is equivalent to "braking" when running.  Ideally our feet will land closer to our center of mass.

Problem #5 – Doing too much too soon

We are all aware of this rule in exercise but I’m mentioning it anyway.  Because you could be doing everything else right but you’re doing more exercise than your body can adapt to within a given time frame.  Remember that exercise is a stress to the body and can depress our immune systems and cause injury when taken far beyond our current abilities.  The key to avoid this pitfall is to ask yourself before your workout, can I actually recover from this workout?  If you’re not getting enough sleep, mobility work, time spent relaxing, or good nutrition, you’re basically a ticking time-bomb for something breaking down.

Whether you visit me in the office or you already have a trusted practitioner, the path to healthy knees should include some sort of learning on your part.  I watch runners flock to quick fixes because they do not understand their problem.  But trust me, no human was born with a Hoka or orthotic deficiency.  If you're anything like the modern human, you probably need a little more balance in your life.  Finding out the true cause should be your aim.  Whatever you do, don't give up on running.

Ref 1: Effects of Running and Walking on Osteoarthritis and Hip Replacement Risk. Med Sci Sports Exerc. 2013 Jul; 45(7): 1292–1297.

Ref 2: Long Distance Running and Knee Osteoarthritis A Prospective Study. Am J Prev Med. 2008 Aug; 35(2): 133–138.

Numbers, numbers, numbers!!!

I have struggled with the numbers game for some time but lately I realize that numbers (amount) do not mean nearly as much as purpose (quality). 

It sad when I see my friends, people I know, and so called experts post how many days they go to the gym,  focus on how many reps they do, and  focus on how many workouts they do.  It's even sadder when they equate the high number of things they do as the main reason for their success.  It is not the high number of things they do, but the quality of what they do.  If you work out hard 6 days a week, do you think that all the workouts are quality?   It's likely a few of those workouts are good but the others are "just get it down" work outs (I like to call them junk work out or for running junk miles).   The just get it done workouts can actually harm you by decreasing neuromuscular improvement or increasing your risk for injury.

If you work out hard all the time or at a high intensity, your body will eventually lose efficiency. 

You are completely taxing your system and not allowing for proper recovery.  Additionally, you should have a goal with each workout that does not include "just make it through it."  Good form, improvement in skill, improvement in strength, and/or endurance should be the goal (pick a primary and secondary goal for each workout).  Another goal should be to not get injured or feel "beat down."  You can have hard workouts that tax you but they should be to test your improvement not the norm.  

Injury occurs from both mental and physical fatigue. 

Injury occurs when you one or more areas are overloaded to the point that they body cannot continue to adapt enough.  So, if you are sore all the time or working to maximum do you think you fatigue mentally and physically?  Do you think you will become stiff and not able to control the movements properly leading to excessive overload?  So, why not try to stay mentally focused and physically able?  Maybe, program in some warm-up and recovery (do not rely on your coach or instructor to do this for you)?

Instead of focusing on hitting the gym, trails, pavement, etc. 5-6 days week, maybe focus on 3 good workout and 2-3 days of mobility and skill building.  

Instead of thinking always about the number of sets and reps, think about good quality reps and sets.  This all applies to running as well.  Instead of always focused on miles or time, focus and quality running that improves your abilities.  Running 100 miles a week without a purpose or goal besides getting the miles is only going to get you 100 miles with some improvements.  It will most likely get you hurt and frustrated as well.   Better every day should be your focus not more every day (more ≠ better, better = better). 

If you are interested in quality of movement and exercise, Natural Performance Rehab offers group classes or individual sessions to help you understand and improve your quality and become better every day.