by Caitlin Noble, PT, DPT
Many runners seek the help of physical therapists to recover from musculoskeletal injuries and stay on track with race goals. With a growing body of evidence behind gait retraining, PTs can use these principles to effectively help runners stay healthy.
Running is a simple motion that lends itself to a convenient form of exercise with minimal equipment required. Many runners log miles to increase fitness, train for an upcoming race, or just to unwind. Importantly, running is shown to reduce the risk of hypertension, hyperlipidemia, and diabetes mellitus,1 and is associated with reduced disability later in life.2 In 2017, 27,222 runners started the Boston Marathon, with a whopping 97% finishing the race.3 The total number of marathon finishers in the United States hit an all-time high in 2014, with an estimated 550,600 finishers.4 Numbers have declined slightly since then, but more than 500,000 finishers were recorded in 2015 and 2016.4 Significantly, the marathon isn’t even the most popular race distance in the US. That distinction goes to the 5k distance, with 8.2 million finishers in 2016, accounting for 49% of all finishers in the United States.5
But there is a dark side to running: injury. From knee pain to achilles tendinopathy, injuries can keep a runner sidelined, wreaking havoc on personal race goals, fitness, and emotional health. Running injury rates from published reports range from 19.4% to 79.3% of runners.6 Runners are at risk for developing patellofemoral pain (PFP),7 as well as overuse injuries like medial tibial stress syndrome, achilles tendinopathy, and plantar fasciitis.8 It’s not easy for newcomers to the sport, either. Novice runners are at a higher risk of injury than more experienced runners.9
Running injuries can become nagging over time, as runners are notorious for gutting through training runs. Along the way, runners often seek out the help of a physical therapist, who will help them work on their range of motion, strength, and other impairments. But there is something else PTs can offer runners: gait retraining.
The following companies offer products that can be used for fitness and rehab programs of all types:
Clarke Health Care Products
GAITRite / CIR Systems Inc
The Hygenic Corp
Technology Tells it Like it Is
Gait retraining uses motor control principles to systematically re-educate faulty components of gait. Gait retraining involves evaluating a runner’s gait cycle, and then providing cues to allow them to make lasting changes in the way they run. More evidence has been published about gait retraining in recent years, and it can be a valuable tool to help a runner recover from, and even prevent, injury. For example, gait retraining has been shown to reduce impact forces and hip adduction during running,10,11 both of which have been associated with tibial stress fractures12 and patellofemoral pain syndrome.13
Plus, gait retraining often gets to the root of the problem. Many runners simply do not have pain unless they are running, says Hannah DePaul, PT, DPT, SCS, CSCS. DePaul is a sports certified specialist who works at Adams Sports Medicine and Physical Therapy, Novi, Mich. She explains that she has treated runners after they’ve had previous bouts of physical therapy for running-related injuries, but no one has ever watched them run.
“You could be missing a key part in getting a runner better,” DePaul says.
When it comes to analyzing runners’ movement patterns, Emily Ferree, PT, DPT, is all about the technology.
Ferree is a physical therapist at Movement First, a clinical biomechanics 3D motion lab in Newport Beach, Calif. At Motion First, PTs provide customized evaluation, treatment, training, and recovery plans for athletes, from weekend warriors to collegiate athletes. Ferree uses high-speed cameras, electromyography, and force plates to gain important insights into patients’ movement patterns.
“We have high-speed motion capture with eight cameras, force plates, and software that knows the difference between the person and a background image,” Ferree says. Ferree uses Simi motion 2D or 3D image-based software from Simi US Motion Inc, El Segundo, Calif. The software can integrate EMG, force plate, and foot pressure equipment into gait analysis. This system uses marker-based automatic tracking to calculate body positions and also has a markerless option to create a 3D image of a patient.
“We get a 3D rendering of that person, and can calculate joint angles, angular velocity, acceleration, anything we need to analyze biomechanics,” Ferree says.
Ferree takes a movement-based approach. Her goal isn’t just to treat a patient’s injury, but to use precise information gained from the running gait analysis to change the way patients move. After taking a subjective history, Ferree gets her runners on the treadmill.
“We will do a movement analysis first in order to not be biased before we put our hands on them,” Ferree says. “We put markers on the patient and record in the frontal and sagittal planes. We record joint angles and create a report based on norms. Then we’ll have the patient run over a force plate to get information about loading.”
Gait retraining, however, does not have to be performed with high-priced equipment. DePaul uses an app called Hudl Technique from Lincoln, Neb-based developer Hudl, which allows a clinician to record a patient while running, and review the video in slow motion, measure joint angles, and make drawings on the video when explaining results.
“You can look at body positions, joint positions, foot strike from stance to swing phase, and you can do a sagittal and frontal view,” DePaul says. DePaul can also send her patients the video so they can review it themselves.
Richard Willy, PT, PhD, uses sophisticated technology at the University of Montana School of Physical Therapy and Research Science to produce meaningful research about running gait analysis and retraining. He wants his data to help clinicians find practical ways to retrain gait. Willy integrates everyday items—like mirrors for visual feedback and wearable devices that track cadence—into his gait retraining methods. Willy and his team found that using a mirror is effective cueing for gait retraining for female runners with patellofemoral pain.14 He has also produced research that found that a relatively small increase in cadence subsequently decreased impact forces, peak hip adduction, and eccentric knee joint work for runners using a wearable device as their cue.15,16
“Most running watches can give feedback about running cadence,” Willy says. “There is good evidence that a small increase in running cadence reduces impact forces and knee loads by about 20%.”16
While Willy uses the Garmin Forerunner 70, from Olathe, Kan-headquartered Garmin, for his research, the Garmin Forerunner 235 is a popular watch among runners, according to Garmin Key Account Manager Anthony Hall. Hall says the Garmin Fenix 5 series and Forerunner 935 take it a step further and will give training status, which tells the runner if they are overtraining or undertraining for their goals. As Hall puts it, the data often validates how a runner feels.
Cue for Analysis
No matter what kind of equipment is used, gait retraining isn’t as simple as giving a patient information about their biomechanical dysfunctions. Ferree says our movement patterns are ingrained in us, right down to our spinal cords. She explains that she uses more external cues, because research shows it is more effective for motor learning, compared to internal cues.17 External cues focus on manipulating variables outside of the body, while an internal cue has a runner focus on a movement of a body part.
DePaul is also apt to use external cueing first.
“In terms of research, it’s found that external feedback has a bigger carryover effect,”18 DePaul says. “External feedback means to think outside of your body, like cueing to increase cadence or to straddle a line to increase stance width. Internal cues are saying things like, ‘squeeze your glutes.’ ”
But both therapists agree that every patient is different, and effective gait retraining is no cookie cutter approach.
“If [external cueing] doesn’t work or someone is having a hard time working on that, I’ll say, ‘Try squeezing your glutes.’ Everyone responds a little bit differently, and I think it’s finding the right cue for the right person. I go to external feedback first, and if that doesn’t work, I’ll try more internal cueing,” DePaul says.
Technologies for Staying in Step
Although there isn’t a bank of research behind it, the AlterG Anti-Gravity treadmill from Fremont, Calif-based AlterG is another way for a patient to practice gait retraining. The treadmill provides a reduced-gravity environment to decrease ground reaction forces. The unweighted environment offers a safe way for a patient to practice increasing their forward trunk lean, an element of running form that promotes hip extension and forward momentum.
The PT market offers a variety of highly adjustable treadmill technologies that provide data about performance. One manufacturer, Spirit Fitness, Jonesboro, Ark, offers the MT200 Gait Trainer Treadmill, which features a speed control motor, an incline motor, and a decline motor. The three motors in unison provide bi-directional training that can be combined with protocols for uphill or downhill. The MT200’s instrumented deck provides basic gait data that includes steps per minute, stride length, and left versus right gait symmetry.
It is true that strength training won’t help change a runner’s gait, but resistance training can help athletes avoid injuries.20 Elastic therapy bands and tubing provide user-friendly, affordable tools therapists can use with their patients in the clinic or provide for home use. These products can be used to exercise the key muscles for runners, like the hips, glutes, and calves. Side steps; hip abduction, adduction and extension; and ankle inversion, eversion, dorsiflexion, and plantarflexion are among the exercises that can be performed with tubing and bands. Sources for these products are plentiful, and include Warminster, Pa-based Stretchwell, which offers the Fitlastic line of therapy bands and tubing made from natural rubber latex. A selection that includes Thera-Band Latex Free Resistance Bands and Loops, Franklin Bands, and Sanctband Resistive Exercise Bands is available from OPTP, Minneapolis.
Training on Task
While having a foundational strength is necessary for runners, it likely won’t improve gait deviations that make runners vulnerable to injury, which was a key finding of one of Willy’s studies. Willy investigated whether strengthening female runners’ hips could influence gait deviations.19 Willy and his team concluded that a training program of hip strengthening, movement education, and single-leg squat training with neuromuscular re-education improved participants’ single-leg squat mechanics. However, it did not alter running mechanics. This suggests that if a clinician wants to improve running gait mechanics, strengthening alone may not be adequate to get the job done.
Overall, gait retraining for runners can be an ongoing process for both PTs and patients alike. When it comes down to it, Willy’s advice is to keep it simple; don’t overwhelm the patient with cues to fix every gait deviation seen during evaluation.
“I think the best thing I can tell clinicians is to focus on changing one gait parameter; it is important to stick with one thing,” Willy says. “Try a few things out to get the change you want. Once you find that, give the runner that cue. Don’t tell runners how to change cadence; just let them figure it out and create a new strategy, so they can learn a new motor pattern on their own.” PTP
Caitlin Noble, PT, DPT, is a physical therapist at Adams Sports Medicine and Physical Therapy, Novi, Mich. Noble earned her Doctorate of Physical Therapy from the University of Michigan-Flint and has a Bachelor of Arts in Journalism from Michigan State University. For more information, contact PTPEditor@medqor.com.
1. Williams P, Thompson P. Walking versus running for hypertension, cholesterol, and diabetes mellitus risk reduction. Arterioscler Thromb Vasc Biol. 2013;33(5):1085-1091. doi:10.1161/atvbaha.112.300878.
2. Chakravarty EF, Hubert HB, Lingala VB, Fries JF. Reduced disability and mortality among aging runners: a 21-year longitudinal study. Arch Intern Med. 2008;168(15):1638-1646.
3.Statistics – Boston Athletic Association – BAA.org. Racedaybaaorg. 2017. Available at: http://raceday.baa.org/statistics.html. Accessed December 26, 2017.
4. 2016 Running USA Annual Marathon Report | Running USA. Runningusaorg. 2017. Available at: http://www.runningusa.org/marathon-report-2017?returnTo=annual-reports. Accessed December 30, 2017.
5. 2017 U.S. Road Race Trends | Running USA. Runningusaorg. 2017. Available at: http://www.runningusa.org/2017-us-road-race-trends. Accessed December 26, 2017.
6. van Gent R, Siem D, van Middelkoop M, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Brit J Sports Med. 2007;41(8):469-480. doi:10.1136/bjsm.2006.033548.
7. Taunton J. A retrospective case-control analysis of 2002 running injuries. Brit J Sports Med. 2002;36(2):95-101. doi:10.1136/bjsm.36.2.95.
8. Lopes A, Hespanhol L, Yeung S, Costa L. What are the main running-related musculoskeletal injuries? Sports Med. 2012;42(10):891-905. doi:10.2165/11631170-000000000-00000.
9. Videbæk S, Bueno A, Nielsen R, Rasmussen S. Incidence of running-related injuries per 1000 h of running in different types of runners: a systematic review and meta-analysis. Sports Med. 2015;45(7):1017-1026. doi:10.1007/s40279-015-0333-8.
10. Clansey A, Hanlon M, Wallace E, Nevill A, Lake M. Influence of tibial shock feedback training on impact loading and running economy. Med Sci Sports & Exerc. 2014;46(5):973-981. doi:10.1249/mss.0000000000000182.,
11. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. Brit J Sports Med. 2010;45(9):691-696. doi:10.1136/bjsm.2009.069112.
12. Pohl M, Mullineaux D, Milner C, Hamill J, Davis I. Biomechanical predictors of retrospective tibial stress fractures in runners. J Biomech. 2008;41(6):1160-1165. doi:10.1016/j.jbiomech.2008.02.001.
13. Barton C, Levinger P, Menz H, Webster K. Kinematic gait characteristics associated with patellofemoral pain syndrome: A systematic review. Gait Posture. 2009;30(4):405-416. doi:10.1016/j.gaitpost.2009.07.109.
14. Willy R, Scholz J, Davis I. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clin Biomech. 2012;27(10):1045-1051. doi:10.1016/j.clinbiomech.2012.07.011.
15. Willy R. Innovations and pitfalls in the use of wearable devices in the prevention and rehabilitation of running related injuries. Phys Ther Sport. 2017;29:26-33. doi:10.1016/j.ptsp.2017.10.003.
16. Willy R, Buchenic L, Rogacki K, Ackerman J, Schmidt A, Willson J. In-field gait retraining and mobile monitoring to address running biomechanics associated with tibial stress fracture. Scand J Med Sci Sports. 2015;26(2):197-205. doi:10.1111/sms.12413.
17. Wulf G, Su J. An external focus of attention enhances golf shot accuracy in beginners and experts. Res Q Exerc Sport. 2007;78(4):384-389. doi:10.5641/193250307×13082505158336.
18. Zachry T, Wulf G, Mercer J, Bezodis N. Increased movement accuracy and reduced EMG activity as the result of adopting an external focus of attention. Brain Res Bull. 2005;67(4):304-309. doi:10.1016/j.brainresbull.2005.06.035.
19. Willy R, Davis I. The effect of a hip-strengthening program on mechanics during running and during a single-leg squat. J Orthop Sports Phys Ther. 2011;41(9):625-632. doi:10.2519/jospt.2011.3470.
20. Lauersen J, Bertelsen D, Andersen L. The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. Brit J Sports Med. 2013;48(11):871-877.