The Fall Guy: The Long-Term Treatment of Trail Running Trauma

Stay the CourseIt happens to all of us. It’s as common as the bonk, and ubiquitous with trail running. The Fall.

Not the autumn leaves, fall – though, often, they rank high among belligerents. The Fall – as in tripping, falling, and acutely injuring something – is so common that most would agree it’s part of being a trail runner. We slip, we trip, and we become one with the Earth – albeit with undesirable speed, force, and impact.

Most recognize that falls cause injury – a twisted ankle, a bruised knee or hip. But less realize the potential of a minor tweak in causing major issues down the road.

[Editor’s Note: You might be interested in our companion piece to this article outlining the what to do immediately upon taking a fall or otherwise getting injured while trail running.]

Here’s how, and how you can keep your two wheels beneath you, and spinning true:

The Stability System

Most runners recognize that “the core” plays an important role in running; though it’s often difficult to articulate why. Here’s my take:

Strength, stability and propulsion begin at the core. Any time all of our weight is placed on a single leg (walking, running, jumping, hiking), the trunk and pelvic stabilizers must hold steady the mass of the trunk atop that single leg.

Moreover, the stability of the trunk and pelvis will “inject” strength and stability into that single leg. It does so via a neurological extension pattern where the trunk, then the pelvis and leg all lengthen. I call this pattern, in standing, The Power Position. While in the Power Position, the muscles of the leg work with less effort, and it is easier to balance.

Strong Vs Sag

The author demonstrating the lengthening trunk and elevated pelvis of the Power Position (left) versus a weakened, sagging stance leg (right).

Try this: facing a mirror, stand on one leg, first with pelvis level, if not slightly lengthened. Then try it with the pelvis in a passive, shortened or hanging position. Which position is easier to balance?

The Power Position represents half of the running pattern, and – as the ground-impacting component – arguable the more important. The other half of the system is the forward and upward (“flexed”) pattern.

After a fall – when tissue trauma or pain is experienced – this pattern can be thrown off by the body attempting to protect itself. The disruption of the running pattern, if it persists, can potentially create other dysfunctions.

Pain and the Body’s Response

When we fall, it usually hurts. Pain sometimes, but not always, is in the company of tissue inflammation – the result of tissue injury. Pain or inflammation in tissues – muscles, tendons, or joints – “turns off” muscle. Receptors in the tissue signal the brain saying, “Hey, something’s off here – if you fire that muscle 100%, you’re going to make things worse.” As such, the brain deactivates that muscle and nerve to protect the area. This is a primitive – but still useful – response to running through the wilderness, spraining a joint, and preventing the prehistoric human (or stubborn trail runner) from firing those powerful muscles that might further damage a compromised joint.

Pain can have the same effect. Even in the absence of tissue damage, pain in an area signals to the brain that “something’s amiss” resulting in decreased muscle activation.

But another primitive mechanism exists. Altered motor plans – or ways to continue to move without using the compromised tissues – allow us to continue forward. In other words: Limping! In a primitive viewpoint, this is so we could still evade predators in the face of injury (or, in a trail runner’s case, a dreaded cut-off time) and survive.

What also happens in the face of pain or inflammation is the loss of the Power Position. The brain, noting that there is compromised tissue in the chain, will attempt to avoid placing the entirety of the body weight through the leg. While that loss of weight reduces stress on the short term, it also robs the entire leg – and movement pattern – of the strength and stability inherent to the pattern.

Not. Good.

As discussed in the first Staying the Course column, pain changes how we move, and limping or compensating can have dire consequences to our running. It compromises the strength, stability, power and efficiency of the pattern – throwing a big ol’ wrench in the works of your stride.

Ongoing compensation – as little as a single painful run – is enough to re-write the motor control pattern of how you run. Consider that how we do stuff – everything from running to brushing our teeth to whistling – is a Microsoft Excel file in our brain. Compensatory movement patterns – limping – is like opening that Excel file, typing a bunch of garbage, then hitting “Save”. The original, pristine motor plan has now been changed, though the brain still looks at the “Run.xls” file as no different than before.

And it’s not just the painful leg that is affected. Because the forward-driving flexion pattern is the equal-and-opposite brother of extension, he, too, can become compromised.

What a mess!

Don’t do it!

Or do it, so we in the healthcare field have steady work…

No, don’t do it. I’m too busy.

Common Delayed-Onset Injuries Stemming From Falls

Most people recognize that a banged-up knee could cause same-sided pain either above or below. Here’s a sampling of what could happen to the opposite side of the banged-up leg:

Where:  and Why

  • Hip Flexor Pain: A compromise in push off on the fall-side results in compromised upward drive, making the hip flexors over-work.
  • Central Knee/Patellar Tendonitis: Similar to above, a decreased push off results in decreased knee flexion in the forward drive. Less knee bending leads to tightness in the knee and patellar tendon, among other issues.
  • Lateral Knee Pain: A poor push-off on one side can result in an inefficient upward drive and downward landing on the opposite side. Often folks with a fall history acquire a “braking” problem on the opposite side, commonly experienced as lateral knee or “IT band” pain.
  • Achilles or Plantar Foot Pain: Same reason as above: a weak push off on the fall side equals a sloppy, out-front landing on the other side. The Achilles (with a forefoot strike) or plantar (heel strike) pain can result.
  • Hamstring “Tightness,” “Ache,” or “Sciatica”: Yet another result of a poor push-off, and opposite side braking. The pelvis absorbs excessive braking forces, resulting in referred pain – usually experienced down the back our outer side of the thigh (frequently mistaken as hamstring tightness or sciatic nerve pain).

Yikes! That’s a lot of trouble simply by running through pain! Don’t do it!

Recovering from a Fall: Acute

You’re running along and suddenly you’re airborne. THUD. You’re down. Now what?

After a fall, take immediate stock?

  • Is anything broken? Are you in severe pain? Take mental and physical stock? Are you OK, in an emergent sense? If so, get up.
  • Can you walk without a limp? Try walking. What hurts? Is standing and walking possible? If so, do it. Does the pain dissipate with time and motion? If so, keep moving… If not, flag down some help.
  • Can you run without a limp? Once you can reasonably walk without a limp, try jogging on a flat, safe surface (if possible). Can you put all your weight on the affected leg, or does the leg simply “give out”? If your leg “gives out”, that’s the brain turning off all the power. Stop. Don’t run. Continue to walk. Give the brain time to restore the power. Once walking limp-free, try running again. Ensure your leg will take full weight without a give-out. If so, proceed with caution. If not, walk it in. Period.*

* Unless you’re on the track at Placer HS in 10th place and see lights coming down Finley Street, then limp like hell for 260 meters! We’ll sort it out later…

Recovering from a Fall: The Aftermath

Once to safety of home, apply the concepts of RICE to the area, as needed. But as soon as possible, apply the concepts of healthy joints:

  1. Full range of motion
  2. Strong, activated muscles
  3. Neutral joint loading

Full range of motion. To restore range of motion to the affected area, perform stretches in all areas, whether to the hip and knee (flexion and extension) or ankle and foot (dorsi-, plantarflexion). It might hurt. Don’t avoid pain, nor ignore it. Work gradually but progressively toward your normal, full range.

Strong, activated muscles. Just because you’ve got a big ol’ quad, doesn’t mean the power’s turned on. Motor control theory tells us that, in order to appropriately use a muscle, we must feel it (e.g., “the burn”). Here are two comprehensive exercises to turn on muscles:

Standing Weight Shift. Place the affected foot forward – ideally on a step – and align the knee over to foot and chest over the knee. Firmly push the leg into the ground. Hold the position until muscle – namely the quadriceps and hip – begins to burn, then hold 5-10 seconds longer. Repeat ten times.

Weight Shift SIDE

The standing weight shift, noting the chest over knee over foot weight-bearing position.

This sounds simple (if not silly), but a majority of injured runners will either have delayed or absent muscle feel in this position. If you can’t feel anything, push harder. Keep trying.

Standing Power Position. Place your hands high on a wall, then drive your unaffected leg upward, while standing on the painful side. Lengthen through the trunk on the stance side. The flexed knee should be directly in front of you, with heel beneath your butt. Hold this position until you feel muscles of the stance leg hip firing…then hold 5-10 seconds more. Repeat ten times.

Power Position BOTH

The “Power Position,” demonstrating the prolonged holding of both the push-off (lengthened) and driving (shortened) leg positions.

If these static positions are significantly painful, back off the duration and reps, and continue to work it until the pain decreases. This could take hours, or days. Only then should you proceed to the motion-based exercises below.

Neutral joint loading. Once muscles are turned on, work on your ability to control your leg normally in space. In running and walking, this is one’s ability to align his or her foot, knee, and hip in a straight (but often angled) line – and keep it there – in dynamic movements. This requires activated and coordinated muscles.

Step Up. Align yourself in the weight shift position. Keeping your knee centered over your foot and your chest over knee, step up, but do so by “pushing” with the muscles of the hip, as you did in the Standing Power Position. Feel the hip muscles – along with the quad – propel you up the step. The difference between a quad-dominant step and a hip/Power Position step-up is subtle but important. Using the Power Position muscles invariably results in stronger, more stable propulsion with better leg control. It also mimics the running push off. Step up slowly, and then reverse even slower. Perform ten, with a goal of thirty consecutive. Mild pain is OK, so long as your control is normal.

Step up FRONT

The step up exercise – start and finish positions. The goals it maintain the straight alignment from hip to foot.

Marching & Skipping. The last step before returning to run, the march and skip incorporate the power position and step up into a dynamic, running-specific exercise. (video)

Note in the video how the pelvis rises up on the upward drive side and lengthens on the stance leg. This is the power position, put to motion. Perform this drill in spurts of 15-20 seconds, aiming for equal feel between both legs.

* * * * *

Performing this series of exercises – range of motion, strong, activated muscles, and neutral joint loading – will promote a full recovery from the fall as well as ensure integrity to your precious running stride. Moreover, these concepts apply not only to falls, but to all injuries, and even post-race soreness – like running a virus scan to “Run.xls”!

Next time you take a spill, don’t just brush off the dirt and leaves. Brush off any threats to your running stride.

Call for Comments

  • How have you dealt with the aftermath of falls in the past?
  • Have you ever had injuries that resulted from your running while favoring/protecting a traumatic injury?

[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 9 comments

  1. Ashley

    I have major issues with my hip flexes and it causes pain in my left knee (probably because I favor it?) if I don't stretch properly.

  2. mtnrunner2

    Being currently lame while recovering from strains of core muscles, I hear ya. It was a combo of twisting while trying to stay on my mountain bike a couple of times, plus the shock of trying to stay up through a couple of trail running stumbles (hamstrings, waist). The impulse to stay upright just kicks in, and puts huge forces on the body.

    When I'm done, definitely working on the core.

    For now I'm just trying to rest and stay stretched out (lunge stretches, yoga cobra, etc.).

  3. Gina

    Hi Joe,

    Just wondering if the above exercises would be useful a year or more post-injury? In my case, a repeatedly sprained ankle that later led to pain in the hip area on the same side. I'm quite sure I've adapted with imbalances to my running form. Is this a good way to start straightening that out?

  4. Jason

    Great article Joe! These posts don't generate the controversy that some do, but they are a treasure trove of facts for us. Especially folks that want to stay healthy and as fast as possible for as long as possible!

  5. OOJ

    Ryan-

    Standard protocol – soft tissue massage (self- or from someone else), stretching and ice work wonders on trashed quads.

    However, there are certain preventative measures for dead quads, namely with ultra running:

    1.) Flat running: be sure to have your trunk aligned forward. A backward trunk and/or foot-strike in front of your center of mass will result in some part of your body (very often the quad) to absorb impact stresses ("braking")

    http://www.irunfar.com/2012/09/give-it-a-brake-fo

    2.) Downhill running: my personal and professional experience has told me that quads "die" (e.g. endure less trauma) during ultras IF you consistently and sufficiently bend your knee in your stride.

    Meaning: is the flexion aspect of your strike (forward drive, heel recovery, knee flexion, etc) adequate on both flats, and downhills? A lot of folks (even the front-runners) can lose the flexion phase with fatigue and slow pace; it's also problematic when "picking" one's way down a steep hill.

    Simply "picking up the feet" on a downhill provides a stretch-action to the quads – relieving a lot of tightness and energy. This sort of "high-knee" downhill stride also lends greater stance leg stability on a descent – win-win!

  6. OOJ

    Gina-

    Sorry for the late response!

    YES, these concepts are extremely important to all injuries, regardless of chronicity, but play a very helpful role in prevention as well as treatment. This is my core "recipe" for lower extremity chain injury, whether the person is a runner or not.

    Give it a try!

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