Anatomy of a Running Injury – Part II

Stay the CourseIn the first installment of Stay the Course, we discussed the two necessary components of injury formation: abnormal forces and abnormal tissues. It takes but one, but more commonly – especially with chronic injury – they conspire.

How, then, do we go about fully and effectively treating a running injury? There are many therapies, medicinals, and gadgets out there. Most, if not all, can be very helpful. Revisiting Dr. Noakes’ Rules of Running Injury, Rule 6:

Treat the cause, not the effect of the injury.

Thus, to truly attack and defeat injury, one must address the following causal elements:

Mechanical – Neuromuscular – Motor Control

These terms – and this treatment approach – are adopted from the curriculum of The Institute of Physical Art, a treatment philosophy in the physical therapy field. The “IPA” teaches coursework to allied health professionals on a variety of areas, ranging from spine care to orthopedics to even visceral (read: guts!) mobilization. But central to all interventions is addressing those three fundamental elements.

Mechanical
This concept deals with the tissue’s ability to move passively. Simply put: can the muscle, tendon, or joint physically move in the way you need it? If not, your body – the brain, nerve, and muscles – cannot efficiently move. It’s like pushing against a brick wall or trying to bend a rusty hinge.

Mechanical restoration is an integral and well-recognized element to treatment. As such, there are thousands of skilled health care folk out there – PTs, chiropractors, massage therapists, osteopaths, to name a few – that skillfully mobilize tissue to normal range of motion and extensibility.

But that is only part of the picture. Without any more, what is to keep the tissue from reverting to dysfunction? This is why tissue mobilization frequently results in only temporary relief.

Neuromuscular
The nerve plus the muscle equal the motor unit. Functional motor units range in size from the microscopic (nerve ending + myofibril) to the muscle bulk, itself. Like a car engine, efficient movement requires we “fire on all cylinders:” each motor unit being activated to assist in the movement.

So what makes a cylinder fail to fire? Inflammation, mechanical restriction, pain inhibition, and changes in motor control can all “turn off” muscle. Neuromuscular inhibition does not mean the muscle is paralyzed or atrophied; instead, it is simply that the brain does not [fully] recognize the motor unit as a useful element in movement – just as the cylinder is intact, yet fails to combust the fuel within it.

Health care folk and runners alike recognize the importance of muscle strength in healthy function. However, simply “strengthening” a muscle does not ensure activation, and more often than not, hypertrophic changes (e.g., muscle growth) is unnecessary… just as the addition of another cylinder to the engine neither fixes the original mal-firing or ensures the new cylinder, itself, will actually fire!

For example, a multitude of studies on patellofemoral pain (e.g., “runner’s knee”) have correlated weakness of the hip abductors to knee pain. Most runners – and sports med docs – recognize this, but few runner’s knee cases are effectively treated with full recovery simply by performing isolated hip abductor strengthening.

Why? Because they’re missing the most important element:

Motor Control
A vitally important (and in my professional opinion, the most important) element of injury treatment is motor control. How do you move your body in space – integrating mechanical movement with synchronous motor unit firing – to achieve a desired outcome? For us, quite simply: how do you put one foot in front of the other?

Motor control is performance – how you do it. It is where the rubber meets the road, and where the buck ultimately stops. Performance is either efficient or it is not. Lucky for us, efficiency is a sliding scale; however, that sliding scale can be both slippery and insidious – where inefficient changes can gradually take place, often without our awareness.

Some important points:

  • Motor control is athletic skill: the integration of healthy tissues and a working nervous system to create movement. As such, to optimize motor control takes far more than “stretching and strengthening.” A clinical pearl I often share: to believe you can improve running mechanics simply by doing strengthening exercises is like telling a golfer with a mean slice that he’ll hit it straight if he does some bicep curls. It might help, but strength is not motor control.
  • Inefficient motor control results in abnormal forces on your tissues and, in most cases, more stress. It is like “slamming your thumb in a door,” perhaps quite gently, but relentlessly. The more inefficient, the more forceful the slam. The best mechanical and neuromuscular therapy is no match for more door-slamming. Sometimes, simply removing thumb from said door is the only therapy necessary!
  • “Pain is the Greatest Teacher.” Running is a natural human movement: ever see a young child run effortlessly with graceful precision on a playground? As a certain book argues, we’re “born” to do it. So how do we get from there, to the “ultra shuffle?”Pain.As discussed in Part 1, pain is a danger signal: of impending tissue damage, or simply fatigue. An automatic response to pain is compensation to avoid loading the affected tissues. And it needn’t be real pain, soreness can have the same effect. Thus, the cumulative soreness from heavy training alone, in absence of any true injury, can potentially alter motor control.

To summarize: motor control is athletic skill, with a quality of efficiency, which is susceptible to change. And poor motor control can result in abnormal forces on tissues.

This brings us to Dr Noakes’ 8th Rule of Running Injuries:

Never accept as final the opinion of a non-runner.

What I believe Dr. Noakes is referring to is the notion that a non-runner lacks the knowledge and/or belief system requisite to comprehensively treat your injury. I don’t fully agree with this; there’s nothing inherently ignorant about non-runners, nor is there an inherent knowledge of running mechanics by expert runners (to the contrary, I might argue – but that’s fodder for a future post).

Instead, I propose a different rule:

Never accept as final the treatment of your running injury until your gait mechanics have been thoroughly examined and treated.

We’re runners, not football players. Our injuries don’t come from tackles or cut-blocks or other “Acts of God” (the infrequent fall being a previously-mentioned exception). How we move our bodies the primary factor in performance and pain. Without thoroughly examining your mechanics in the treatment, how could you expect forces to return to normal?

Analyzing and training gait mechanics is hard. But so is orthopedic surgery and there are tons of skilled surgeons out there. If your sports medicine practitioner doesn’t look at how you run, ask them. If you get a blank stare or a paled expression in return, you need to go elsewhere. There’s a lot of skilled folk out there. Ask around.

* * * * *

Let’s now briefly return to the example from Part 1: the woman with left knee pain. Here are the issues to consider:

Mechanical: Knee, ankle, and hip flexibility – do they allow normal, fluid stride mechanics? This required joint mobilization and stretching techniques.

Neuromuscular: During strength and movement testing, she notes being unable to feel her glut muscles. Absent of true atrophy, this represents a neuromuscular deficit. Sustained holds of standing hip abduction/extension positions were used to “turn on” these muscles.

Motor control: A close examination of her run stride reveals significant issues:

–       Excessive vertical forces (“bouncing”) and a lack of forward propulsion

–       Medial knee collapse (a by-product of that vertical energy / lack of propulsion)

–       Lack of normal knee flexion on the affected side – a compensatory pain response from three months of knee pain – all three of which she was completely unaware.

Specific run drills and proprioceptive cueing (e.g., “can you feel this?”) were used, along with guidance to avoid any limping or favoring, with her return to running.

I’m happy to report that, after three months of pain, this runner has now returned to running, thanks in large part to this comprehensive approach.

Finally, if that weren’t enough, I will add one more important factor: Inflammation. Even with skillful treatment of Mechanics, Neuromuscular, and Motor Control, sometimes tissues are just, plain irritated. Give them the time to rest and repair – all the while addressing those “Big Three” factors. Sufficient rest and gradual build-up will ensure that you keep both tissues and forces normal, and your running happy and healthy.

To summarize:

  • When injured, be sure to consider all three factors: Mechanical, Neuromuscular, and Motor Control.
  • Insist that your sports medicine professional closely examine your run mechanics. If they won’t or if they don’t have that skill set, find someone who does. It may be the most important thing you do.
  • Don’t underestimate the importance of rest and gradual build-up in your return to training. Even perfection on irritated tissue can perpetuate pain.

Call for Comments

  • What are your experiences with injuries requiring Mechanical-Neuromuscular-Motor Control approaches to rehabilitation?
  • Have you ever attempted to change your stride mechanics? If so, why, how, and how did it work out for you?

[The contents of this column as well as the author’s comments are provided for general informational purposes only and are not intended as a substitute for professional medical advice. Do not use the information on this website for diagnosing or treating any medical or health condition.]

Joe Uhan

is a physical therapist, coach, and ultrarunner in Eugene, Oregon. He is a Minnesota native and has been a competitive runner for over 20 years. He has a Master's Degree in Kinesiology, a Doctorate in Physical Therapy, and is a USATF Level II Certified Coach. Joe ran his first ultra at Autumn Leaves 50 Mile in October 2010, was 4th place at the 2015 USATF 100K Trail Championships (and 3rd in 2012), second at the 2014 Waldo 100K, and finished M9 at the 2012 Western States 100. Joe owns and operates Uhan Performance Physiotherapy in Eugene, Oregon, and offers online coaching and running analysis at uhanperformance.com.

There are 28 comments

  1. Chris

    Joe, thanks for the article. Can you explain "could not feel her glute muscles" ? Does this mean inability to fire the affected side's muscle as clearly as the healthy side, while not running?

  2. OOJ

    Chris-

    In this specific example, she was performing a standing hip exercise, and, with a prolonged hold (>10 seconds), she was unable to "feel" the muscle activation.

    There are several motor control theories out there, one of which states:

    For the brain to effectively/fully utilize a muscle in a particular movement pattern, it must be able to *feel it*.

    A good example of not feeling a muscle is someone with knee pain/poor knee control – unable to feel their quadriceps muscle (again during a prolonged hold). This represents what we can a "proprioceptive deficit" — or a poor electrical connection between brain and muscle. A "normal" response is to be able to feel a muscle with a prolonged hold in <5 seconds (think about holding a squat and how fast you'd feel your quad…theoretically).

    As for feeling it vs not, while not running: you can infer that to be the case, but not always. Because running has such a close association in motor pattern to walking, you could infer that deficit also exists in non-running, too.

    1. OOJ

      I don't know of any specific folks off-hand, but I am biased towards "Functional Manual Therapists" (credentialed through the IPA) — they are certified in the methods of looking at the "M-N-Ms" as we call it:

      http://instituteofphysicalart.com/ipa/referral/li

      Don't hesitate to call or email any of these folks (or anyone you've read or heard about) and ask them about their comfort/ability to look at gait mechanics!

        1. Daniel

          All of the names on that first list were from the eugene area, and I see you`re from eugene. Can you help me yourself? or name anyone who can?

  3. Chris

    Joe,

    OK thanks, I get it. I have a left IT issue, and have noticed that, standing, I have trouble activating/coordinating the left glute (the right activates ok), though I can do one-leg left squats ok. Would simply standing and repeating firing the left glute be a good start?

    1. OOJ

      Chris-

      You're best off doing exercises/drills as specific to running as possible. Unfortunately, without looking at your gait, I can't say for sure what you need, or what would help.

      Here's a BRIEF (not exhaustive) lists of things I would look at for in the three categories for *lateral knee pain* (ITB or otherwise)

      MECHANICAL

      ITB tightness

      Hip/pelvic mobility (sidebending, hip extension, sacroiliac joint motion)

      Ankle/rearfoot mobility

      Full knee exam (lateral knee stability, patellar mobility)

      NEUROMUSCULAR

      Glut max/glut med functional strength (muscle test, "can you feel it")

      Core stabilization (both L and R side) – ability to hold trunk firm with perturbation of legs -or- how stable the trunk/pelvis is with a simple step down

      MOTOR CONTROL (run gait)

      Are you braking in front of your center of mass?

      Are you lateral foot striking on the L?

      Are you bouncing (excessive vertical excursion — using quads/calves instead of trunk/pelvis/hips for propulsion)

      Those are things I'd look at as a coach/clinician; as a runner, you could look at your stride simply by getting on a treadmill with a mirror at your side.

  4. dogrunner

    This is great stuff. If I print this out and bring it to a PT the next time I have an injury, will they appreciate it or tell me I spend too much time on the internet? :)

    I really do think Joe presents a very sensible practical approach to injury, but am always concerned about implementation. And I really have no idea what sort of training PTs might have with respect to running injuries.

  5. Brian G

    This is probably the best online article outlining how great an impact improper muscle activation can result in injury I've seen.

    Except for a car injury (my back) and something that had to be corrected via orthopedic surgery (my shoulder) I'd say that every time I had to go see my PT for an injury — and they've been all over the place on my body — the underlying cause for all of them was improper muscle activation causing pain and irritation elsewhere.

  6. Matias Saari

    I have been fortunate to be injury-free for years, particularly after switching almost exclusively to trail running.

    But like just about everyone i hardly have perfect mechanics. Could you elaborate on efficient gait mechanics in a future column?

  7. OOJ

    Dogrunner-

    I think it'd be doable to give to a therapist — MDs get that all time (meds, treatments, etc). You might frame it by saying, "What do you think of this?". You might also simply e-mail them the link.

    Never forget, runners: YOU are the consumer of health care. That means that you need to shop around for what you need (to find someone out there who can deliver "3-dimensional care" that is *runner specific)*, and ultimately ask for what you want – or think you need. Then you work together for the desired outcome, as a "sports medicine team". :)

  8. Jeremy Robillard

    Dr. Snell at Hawthorne Wellness is great. He is a runner, up-to-date and has a clear philosophy to get you back to health. I highly recommend calling Dr. Snell and getting an appointment.

  9. adam

    OOJ – Thanks for the great start to your column. I'm a Physical Therapist and I feel The Anatomy of a Running Injury Part I and II articles are a great representation of injury and contemporary rehabilitation. I look forward to your future columns.

    Dogrunner – If a patient brought me this article I would be psyched. I work in Los Angeles and see many patients interested in the latest fad technique or machine. It's always a yellow flag when I meet any clinician (or patient) that refuses to listen or gets defensive when presented with information.

    Joe's section on motor control describes the practice of the better clinicians regardless of training (PT, chiro, osteopaths, etc.). Movement occurs in patterns whether we bring a spoon to our mouth or run single track. Isolative exercises are limited in addressing movement problems and if a clinician is not addressing motor control you should seek another opinion.

  10. Cheri Hall

    Joe,After 3 doctors I finally found out what is wrong with my ankle. It has been going on for a yr.and 2 months. Dr. Burrow said I have ostechrondritis. He put me in a cast/crutches for 6 weeks with a 50/50 chance of healing. I was told I have 2 options cast or surgery. Please tell me about this condition. I have been reading and researching it on the net. It does not sound good. I live to run it is what I look forward to everyday of my life. I am alittle scared of the future of what this injury will bring to my running. Any help you can give me will be a blessing. Thank you.

    Sincerely,

    Cheri

  11. OOJ

    MS-

    "Efficient Gait Mechanics" — a salient topic, but a loaded one. Kind of like asking Mr Roes, "How do you win a 350-mile race in the Alaska winter?" :p

    My goals is to chip away at it — discussing portions here and there — over the coming weeks. While "efficient mechanics" might be universally agreed upon, exactly *how* you get there is as debated as any other topic in distance running!

  12. Marco A.

    Joe, interesting I formation you present .

    I would appreciate your input on back injuries. how these injuries alter ones running or how one can recover back to running, running far.

    To be specific in the injury: herniated disc between L4-L5 which I sustained 2 days ago.

    How: performing moderate weight dead lifts .

    According to the Emergency MD, no running in the near nor distant future. I'm to see an orthopedic MD in a few days but I am eager to hear from someone who is in the sport and has an educated experience with back injuries.

    Miles of thanks,

    Marco

  13. OOJ

    Marco-

    Sorry to hear of your injury! Let's break this down into the "3" categories:

    0.) Inflammation: You've incurred what sounds to be a serious back injury. In the very least, it will require ten to 21 days to heal — minimum (that being the accepted time an inflammatory response takes to "heal"). However, it make take even more than that, depending on your symptoms (nerve tissue, if involved, can take much longer), and pain response to "non-running things". The general rule is that one shouldn't run until they can walk a mile without pain.

    1.) Mechanical: Here are *some* of the things I would consider looking at:

    – Full range of motion in the spine and pelvis (all planes), as well as normal/full hip mobility

    – Normal motion in the rest of the legs (knees, ankles/feet)

    – Normal nerve tissue mobility (if there is any "sciatic" symptoms)

    2.) Neuromuscular:

    – Normal, strong activation of core stabilizers

    3.) Motor Control: While you might've herniated your disc while weightlifting, one might speculate the factors that might've predisposed the disc toward degeneration. Here's what I would look at:

    – Walking & running mechanics: are you using your trunk, pelvis, and hips efficiently to "cushion your ride" while running/walking? Stiffness in any of these elements could irritate your back and make a return to running difficult.

    Back injuries are notorious "pain educators" — changing the way we use muscles and move our bodies. My final – and ultimate – goal for you would be to ensure you're moving efficiently (in and out of the running shoes) when you get back to running.

    Again, your goal should be to find someone who's skilled in "motor control" — walking, running mechanics. They'll be best equipped to help you with 1-3 after you and your doctor have helped get you through #0!

  14. Marco A.

    Thank you for taking the time to reply.

    You are spot on, you echoed my MD's words which is reassuring. Physio-theraphy and Pilates after 4weeks of rest for healing.

    Miles of Thanks

  15. Dana

    I’m late to this party, but just had a great “Never Limp” experience last week.

    I’ve been having chronic Achilles trouble, and in the past year I’ve realized that it’s tied to gluteal dysfunction. I went through an intense program of isolated glute strengthening, with no effect on the Achilles. Then I added skipping/bounding drills (pounding my heel into the ground as hard as I could, over and over), which immediately lessened my heel symptoms. A drill that made me stabilize in the stance phase before pushing off, overcame my body’s instinctive resistance to weighting my ankle in dorsiflexion. It had become a vicious cycle of Achilles pain -> overstriding -> calf tightness – but I’ve finally figured out how to fix it.

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