Does Running Ruin Your Knees?

Most of the group of guys that I tend to golf with know that I run quite a bit and occasionally, some comments are made. Last week, one of them got a very serious tone (which is a rare thing with the guys I golf with). With all sincerity, he cautioned me, “You should be careful. Of all the guys that I hung around with when I was younger, the guys who used to run are now the ones having knee and hip problems. You know running ruins your knees, right?”

Deep
breath…

Hang on a minute there Skippy…” is what was on the fast track from my brain to my vocal cords, but I managed to come out with a more polite response. “Well, the research doesn’t actually back up that statement, in fact some of it says the opposite.”

My buddy didn’t really care to hear about clinical research studies and the conversation quickly died out since after all, we were golfing and conversations never last long when the beer cart pulls up.

Hopefully, you are reading this because you are interested, so lets take a closer look at the studies:

Studies Linking Running with Arthritis:

Marti et al [1989] compared hip x-rays in 27 elite runners, 9 bobsledders, and 23 sedentary people. The runners had the highest evidence of arthritis in the hips. Age, mileage, and running pace were independent predictors of hip arthritis. For example, running more than 65 miles per week was associated with significantly more degenerative changes on the x-rays. Faster running pace was an even stronger predictor of degenerative changes than running mileage.

Cheng et al [2000] surveyed 17,000 clinic patients over a 25 year span looked at the relationship of self-reported physical activity and physician-diagnosed osteoarthritis. They found increased physical activity was associated with increased arthritis, including running more than 20 miles per week in men younger than 50 years. However, no association was found with physical activity levels and osteoarthritis in women or in men older than 50 years.

Studies Reporting No Link Between Running and Arthritis

There are far more studies in this category. I will only outline a few but trust me, if I discussed all of the articles that refute running being associated with arthritis, none of you would continue to read this – with or without a beer cart distracting you.

Sohn et al [1985] looked at 504 collegiate cross-country runners vs. 287 collegiate swimmers. They surveyed them between 2 and 55 years after graduation and found severe hip or knee pain in 2% of the runners compared with a 2.4% of the swimmers. They found no differences in pain between the high mileage and low mileage runners.

Kohatsu et al [1990] took a history and did physical examinations and x-rays of 46 people with severe knee arthritis and compared the results with 46 age matched controls. They found twice as many runners in the control group than in the arthritis group, suggesting that running may actually have a protective effect against developing osteoarthritis.

Cymet et al [2006] was a review study, done solely on long-distance running. They found it does not increase the risk of osteoarthritis of the knees and hips for healthy people and “that this activity might even have a protective effect”. They went on to tout the other benefits of running by citing other research findings: “Running has been shown to decrease the risk of cardiovascular disease,diabetes mellitus, and depression. This kind of physical activity has also been shown to help with weight control, to improve bone density, and to decrease mortality.

Bosomworth [2009] – This study reviewed all previous studies done up until January 2009. They found that:

  • The best evidence suggests that exercise, at least at moderate levels, does not accelerate development of knee osteoarthritis. Running seems to be particularly safe.
  • marathon running does not seem to induce changes in joints or increase the risk of osteoarthritis in most studies.”
  • There is evidence for reduction in lower-extremity disability and all-cause disability in self-selected runners compared with controls.”
  • There is some evidence for prolongation of lifespan in self-selected runners.”

Discussion:

In the most recent review of all the literature, Henson et al [2012] concluded, “The existing literature fails to support an association or causal relationship between low- and moderate-distance running and osteoarthritis…Inconclusive evidence exists regarding high-volume running and the development of osteoarthritis.” They go on to say, “The existing literature supports the assertion that older runners are generally healthier than their nonrunning counterparts.”

When you consider that running has been shown to reduce the risk of stroke [Williams 2009], marathoners reduce the risk of hypertension, diabetes and high cholesterol [Williams 2009], improve moods [Schneider 2009], increase bone density [Wilks 2009] and just generally decrease disability and mortality [Chakravarty 2008], it becomes hard to argue that “running is bad for you

Here’s the caveat: These studies are all looking at associations. Maybe, just maybe, people who run their whole lives are living different lives than those who don’t run. Maybe those who don’t run also don’t eat as well, maybe they also smoke, maybe they are more obese (which has a huge association with knee and hip arthritis.) This reminds me of a study that recently came out that said men who skip breakfast have a 27% higher chance of a heart attack during a 16 year study. Well, maybe those men who skip breakfast are just generally less healthy. Are those the guys who will eat less healthy food as well? Are they the guys who don’t get up early and exercise? Are they the guys who skip breakfast because they were up later at night? There are a lot of variables.

What we can say, is we are pretty sure that in general, running does not “ruin” your knees. As usual – proper running form (via Running Reform) with careful, and thoughtful training including gradual increases in mileage and pace are recommended.

Examining a New Study: Pronation Not Linked to Injuries

“So doc, what kind of running shoe should I be in?”

A seemingly straightforward and innocuous question, but one that will take much longer than most people’s attention spans will last. This blog post examines a new study talking about exactly that question and it is grabbing headlines.

If you are short on time and don’t like details, let me sum up the conclusions of this post: When it comes to linking pronation to injuries, it is a highly confusing and gray area. Nobody knows for sure what type of shoe you should be in unless in some cases, muscle/tendon/joint mechanics can be extrapolated from your injured tissue. What we do know for sure, is that it is inaccurate (I’m being polite) for someone to recommend a shoe based off of the shape of your static foot type (high arches, flat foot etc) and even if you have a gait analysis, it is very tenuous to recommend a shoe based on the gait analysis and nothing else. I previously wrote a very detailed article on pronation (patient version found here clinician version found here) and concluded that your shoe choice is a personal one, based on how it feels to you and also based on your injury history with shoes of that type.

The impetus behind this blog is a new study that was just released in the British Journal of Sports medicine called, “Foot pronation is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1-year prospective cohort study” On its surface, this study sounds like the nail in the coffin for the idea that “over-pronating” is the cause on injury. (If you read my other post on pronation you know that I already don’t like the idea of “over-pronation” and injury because it’s way more complicated than that and the research is very, very mixed whether “over-pronation” and injury is a valid and/or reliable association and/or cause.) However, this newest study is…nothing new. This newest study didn’t actually measure pronation during running or walking. Nope, this was a static, non-moving measurement of foot type based on the “foot posture index”. In other words, they had researchers measure the foot arch height of 927 novice runners, put them all in neutral shoes and then followed them for a year to see who got injured. In the end, those runners who were labeled as “pronators” actually had less injuries than “neutrals” (based on their static foot type).

So, of course, the media is going to run with this one (no pun intended). It’s already started with article titles like “Researchers Explode the Myth about Running Shoes, Injuries” and “Corrective Running Shoes are Based on a Myth” but this newest study doesn’t tell us anything new. The idea of basing a shoe off of a runners foot type has been proven incorrect many times before. Below I have listed some studies that clearly have shown that measurements of the foot do not predict how the foot behaves when the person is walking or running:

1. Razeghi M, Batt ME: Foot type classification: a critical review of current methods. Gait and Posture 15: 282, 2002.
2. Hamill J, Bates BT, Knutzen KM, et al: Relationship between selected static and dynamic lower extremity measures. Clinical Biomechanics 4: 217, 1989.
3. McPoil TG, Cornwall MW: The relationship between static lower extremity measures and rearfoot motion in gait. The Journal of Orthopaedic and Sports Physical Therapy 24: 309, 1996.
4. Cashmere T, Smith R, Hunt A: Medial longitudinal arch of the foot: Stationary versus walking measures. Foot and Ankle International 20: 112, 1999.
5. Trimble MH, Bishop MD, Buckley BD, et al: The relationship between clinical measurements of lower extremity posture and tibial translation. Clinical Biomechanics 17: 286, 2002.
6. Dicharry, JM et al., Differences in static and dynamic measures in evaluation of talonavicular mobility in gait. J Orthop Sports Phys Ther. 2009 Aug;39(8):628-34.

This latest study only adds to the pool of evidence verifying that the feet of a moving person do not behave in a way that can be predicted by looking at a non-moving foot. There are too many moving parts that need to be accounted for when running compared to standing. Motions in the pelvis and hip can dictate what happens at the knee, shin and foot. In fact, when this was examined in one study (to my knowledge, the only one to do so) found that when walking or running, control seems to be from the top down, not from the bottom up. In other words, more often than not, your hip and pelvis dictate what your foot will do when walking or running.

So what’s a person to do? There are a few things that need to be considered:

1) If you are happy with your shoes and you are rarely injured even with higher mileage, I think you stick with the shoe type you have been in.

2) If you are injured, you need to take a serious look at your training. I believe most running injuries are from a) ramping up mileage too quickly b) running too fast, too often c) too many miles in general.

3) If you are still getting injured, get a full body gait analysis and look into the credentials of the person looking at your form. Do they know anatomy and mechanics, or did they read “chi running”. No, this statement isn’t based on research reviewed in this paper, but since the research suggests that the mechanics are “top-down”, you need to look into the stability and mobility of the hips, pelvis and core. You may have some hip or pelvic mechanics that need changing.

Obviously we feel that we are well positioned to do the gait analysis.  We have been doing full body gait analysis for 15 years and videotaped around 1,000 injured runners.  We take many post-graduate classes on running injuries and biomechanics.  We both studied kinesiology as our undergraduate programs before chiropractic school.  As this entire post points out, there are many commonly held, but false beliefs regarding running mechanics.  One needs to stay on top of the research.

Retul: 3D Motion Capture Bike Fitting

Your bike should fit you like a glove, and hopefully better than O.J.’s glove. The folks over at Retul have developed a system to make that a reality.

I was recently certified by Retul as a bike fitter. Does that mean I will be doing bike fits? Well, no, but I might be helping out once in a while at the new Rev3 Triathlon retail store opening in Manassas sometime next year. This newsletter outlines a tool that they are already using over there to get cyclists and triathletes properly fit on their bikes and the Retul system is nothing short of amazing…

Analogy alert!…We know from many studies (see here) that looking at the non-moving foot is a terrible way to figure out what kind of shoe you should wear. This is because of the simple fact that the shape, flexibility and control of the foot is much different when you are running than when standing or laying on a table. Those that have high arches may not when they run. Those that seem to be flat footed when standing may control their foot very well when they run. You just don’t know until you examine the moving foot.

Getting the proper fit on a bike is no different. Measuring the body in a static position does not represent what will be happening when you are actually pedaling. For example, do you have poor hip mobility that will cause you to rock back and forth? Do you point your toes down once you start pedaling? Do your knees track toward or away from the top tube when trying to get some power? If the fitter moves the saddle back a centimeter, how do you react to that in your knees, hips and ankles? These are all questions that you cannot know from a static measurement.

Enter the Retul Bike fit. Retul uses a 3D motion capture system that provides real time kinematic data showing knee drift to and away from midline, joint angles at the top and bottom of the pedal stroke for the hip, knee, ankle, shoulder, elbow etc. and it is all done on a bike that can be adjusted on the fly. In other words, we can move the saddle up, down, back and forth and the handlebars up, down, back and forth while you are pedaling so there is instant feedback for how the changes affect how you feel on your bike. Not only how you feel, but how your body reacts to the changes because the system is measuring 3D data of you pedaling with down to millimeter precision. This eliminates the guesswork.

For example, we recently had a triathlete who’s knees were too bent at the bottom of the pedal stroke. By raising the saddle a bit, you would expect the knee angle to open up at the bottom of the pedal stroke. Is that what happened? Nope, the knee angle stayed the same, because he compensated by increasing the toe down position of the ankle. We would never have known that without the Retul system.

Video of the Retul System in Action:



I have had three different bike fits in the past five years. Two of them were done in the standard fashion: You get on the bike, pedal for a bit, the bike fitter uses a goniometer and a plumb bob to get some measurements and then asks you to get off the saddle so he can move the bike saddle and handlebars around a bit. He then rechecks the goniometer and plumb bob and then asks you to pedal again.

Bike Fitter: “How does it feel now compared to before?
Me: “Ummmm…Good, I guess…I don’t know, can you move it back to the way it was so I can feel the other way again?
Bike Fitter: “I hate you

After these exchanges, he is satisfied that he measured properly and you’re on your way. Contrast that with the Retul system where there is no guesswork for the bike fitter (via the data) or for the cyclist (via the instant feel for the bike change).

After the Retul bike is configured to the way both the fitter and the cyclist are happy, the bike is “Zinned”. The fitter takes a “magic wand” and maps out the 3D data points of the bike so the bike fitter can precisely save your fit electronically and then creates a report telling them how to exactly replicate that fit onto your bike or any other bike. Again, the guesswork is eliminated.

Just take that report to any bike dealer, ask them if the fit can be replicated on the bikes that they sell. If it works, test ride that bike with your exact fit to make sure that you are happy with the bike. Now you can go into any bike store without fear and know you are getting the right bike for you.

If you are interested in getting a bike fit over at the Rev3 Triathlon retail store via email: bikefit@rev3tri.com

Painkillers – Running the Risks

Nobody ever said running a marathon was easy or comfortable. Getting to the start line uninjured is a task all by itself, and completing the marathon can be arduous and painful. Many people would like to make it less uncomfortable by taking some pain relievers right before the race starts and hope that these medications will ease the pain during their path to the finish line. According to a new study, this would be ill-advised.

Here’s the quick summary – researchers did a survey of 7,048 marathon runners in the 2010 Bonn Marathon. 4,000 of them returned their questionnaires. Of those 4,000 runners, 61% of women and 42% of men took painkillers (analgesics) before the race. 93% of them said they were never told about the risks associated with taking these meds in connection with endurance sports (hence, the reason why I chose this topic for the newsletter).

OK, the results…

The analgesic group overall had 5 times the adverse effects compared to the non-analgesic group. These included gastrointestinal cramping and bleeding, blood in the urine and cardiovascular events (both heart attacks and palpitations)

adverse events from NSAIDS in marathon

When we take that data and screen out the less to moderate adverse events, we are left with those who suffered more serious health problems – those that required hospitalization within 3 days following the marathon. Overall, there were 9 marathoners that required hospitalization – all of them were in the analgesic taking group. Of those 9, three were because of renal problems (too much urinating, no urinating or blood in the urine) and all three of those had taken ibuprofen. Four of the nine in the hospital were because of gastrointestinal bleeding (all four had taken aspirin). The other two of the 9 in the hospital had suffered heart attacks (both recovered) and both had taken aspirin before the race (one took 100mg, the other took 500 mg)

In an ironic twist, those that took analgesics were more likely to have aches and pains after the race.pain after NSAIDS in marathon

DISCUSSION:

All of the adverse events were dose dependent. In other words, the more meds you take, the higher the risk of bad stuff happening to you. Not surprising. What is surprising to me is that 93% of the respondents report that they were unaware of the risks involved. This was all reported in an earlier study (Gorski et al., 2010) in the 2008 Ironman Brazil were they found “high prevalence of NSAID consumption, limited awareness of the effects and side effects of them and a high rate of nonprescribed use.”

Moreover, this current study found that most of the runners taking analgesics took them at “supratherapeutic doses”. In other words, more than what is recommended.

Unfortunately, many endurance athletes think that these meds will decrease pain and increase performance. This study found that there was in fact more pain reported in those taking analgesics, however, this could be explained in a number of ways. For example, of those taking the meds, 11% said they had pain before the race started, compared to 1% who didn’t take the meds. In other words, they may already have had some sort of injury. Also, these analgesics tend to have a half life of about 2 hours, so it is possible that those taking the meds took them at or near the beginning of the race, but stopped taking them in the latter half of the race. This trend was reported by Nieman et al 2006, when surveying runners in an ultramarathon in 2006.

That same researcher (Nieman) wrote an article in Marathon and Beyond where he talked about his previous research papers and stated, “We were unable to measure any benefit of using ibuprofen by WSER [Western States Endurance Run] athletes, only harm…Every indication from our research showed that ibuprofen amplified inflammation and oxidative stress while providing no relief from exercise effort or muscle damage and soreness.” I would highly recommend you read that article in Marathon and Beyond, as there are plant based anti-inflammatory alternatives recommended by that same researcher.

So there you have it. There is growing evidence that taking these meds before and during endurance events is a risky, ill-advised choice. I won’t pretend that I haven’t done it before during any marathons or Ironmans that I’ve done. It’s not that I was unaware of the side-effects, I just didn’t realize the risks were that high. Better to be safe than sorry. Besides, who said you shouldn’t feel a bit of pain during a marathon? Was it supposed to be easy?

The Unintended Consequences of Limiting Pronation

Lately we have seen an increase in the amount of anterior ankle impingement in runners, so I thought I’d make a post about it.

First, the patient’s version, and if you’re really interested, the clinician’s version is further down the page.

Patient’s Version

Dorsiflexion is the closing in of the angle between the front of your shin and the top of your foot. It is what happens when the knee travels forward over the foot during running, squatting, or getting up out of a chair. Many people have limited range of motion for dorsiflexion.

There are several strategies to compensate for this while running: shortening your stride length, lifting the heel early or reducing the amount that your knee bends. There is also a key strategy in the foot and that is to increase the amount of bending within the foot (called midfoot dorsiflexion). The only way to achieve more of this is by pronating the foot (allowing the inside ankle bone to roll inward)

To prove this is easy – simply do the two different calf stretches shown in the diagram below. You will find that your knee can travel forward further when the foot is allowed to pronate.

If you are told that you “overpronate”, you need to consider WHY you were told this (you can read my take on “overpronation” here). There are many reasons why people are told this. Some are legitimate, some are questionable. Here is one example: Are you pronating a lot to compensate for limited dorsiflexion in the ankle? If you are, and you make attempts to limit this compensatory motion, you are now placing more of a burden on the dorsiflexion at the ankle. This may place you at greater risk of injury.

In my office, I see quite a few people who suffer from “anterior ankle impingement” and it is often because they have stiff, inflexible joints in the midfoot and also we see it in runners who have been limiting the pronation in the foot via over-the-counter pronation control footbeds and/or pronation control shoes.

Find the cause and fix it.

Clinicians Version

The total amount of forward tipping angle that the tibia achieves over the foot during dorsiflexion (DF) is derived mainly from two components: the DF at the ankle joint and the DF from the foot. It is thought that the majority of DF in the foot comes from the midtarsals (calcaneocuboid and talonavicular), but there is also contribution from the tarsometatarsal joints. Running gait requires approx. 20 degrees of ankle DF which is significantly more than with walking [Dugan et al., 2005]

Unfortunately, it is common to find a restricted amount of ankle DF in many patients. During the gait cycle, people can compensate for limited ankle DF for in many ways. From a proximal compensation, runners can shorten their step length, have an early heel rise, or reduce their knee flexion. It can also be compensated for more distally by increasing pronation in order to allow more DF in the midfoot [Johanson et al., 2008]. This is because the midfoot is relatively immobile when the subtalar joint (STJ) is supinated, but increasingly more mobile as the STJ is pronated [Karas et al., 2002]. Pronation of the STJ allows the midtarsal joint axes (talonavicular and calcaneocuboid) to become parallel, which increases mobility [Dugan et al., 2005]

This short 1 minute video helps explain:[vimeo]https://vimeo.com/65147465[/vimeo]

This is important to consider, so I will repeat….Midfoot motion is dependent upon STJ pronation. Without STJ pronation, very little dorsiflexion from the midtarsals can be achieved. [Karas et al., 2002].

Why do we care about all that?

When runners go and purchase shoes, they are usually evaluated for pronation (You can read my take of “overpronation” here). If they are deemed to pronate too much, they are put in OTC footbeds and/or shoes designed to reduce pronation. If they are put in the dreaded “overpronation” category, are they ever evaluated as to WHY they are overpronating? There are many reasons why people pronate, but I have listed just one of them in this post: to help achieve adequate dorsiflexion.

If they have some amount of ankle equinus and they are relying on midfoot motion to attain suitable dorsiflexion, why would you attempt to stop that? Why not fix the origin (in this case, reduced talocrural dorsiflexion)? But very few people are checking for the “reason” there is excessive pronation.

Lately, my office has seen a surge of anterior ankle impingement cases, resulting in cartilage degeneration and tibiotalar osteophytes. Too often, there has been some pronation control device behind the scenes, limiting STJ pronation and thus limiting midfoot dorsiflexion which inevitably results in increased reliance on ankle dorsiflexion and tibiotalar impaction.

Find the cause and fix it

Pulling the Stretchy Tape Over Your Eyes

Working in my own office provides a sheltered, controlled setting. However, my eyes were opened for the past 4 years working for Rev3 triathlon as their Active Release Techniques coordinator. As I estimate it, I treated about 2,000 triathletes over those 4 years and heard stories of frustration and anguish about their musculoskeletal complaints. Being in this setting, I was out of my own sheltered clinic and was able to peek into the current treatments these triathletes were receiving. One thing that I was initially astonished by, but later learned to just shake my head about was the excessive, unabashed use of colorful, stretchy tape that was plastered all over legs and shoulders.

Triathletes are adventurous by nature and are willing to try just about anything to get them through a race. I get that. However, the therapists/chiropractors in their home towns were often sticking this tape on their patients skin without ever getting to the cause of the problem. Even worse was that these triathletes were telling me that their therapists/chiro’s were billing their insurance companies for them to put this stuff on their patients. One could argue this is possibly insurance fraud and if you need the evidence on that, click here and be taken to the bottom of this page for the info.

Equally strange is the idea that you need to be a clinician to slap this stuff on your skin. In the “does it work?” section below, you will find that it doesn’t matter if it’s put on correctly, or even in the reverse! However, if you want to believe it works, there are videos all over the web showing you how to do it. It’s not rocket science. See here, here, here, or here. So why would anyone need to make an appointment and pay outrageous rates? Here is a sample from another provider’s webpage:

I really don’t take issue with some clinicians utilizing conservative treatments that have a lack of scientific evidence because it has yet to be fully studied…as long as it makes rational sense. However, when you are utilizing things that have actually been proven to NOT be effective, that’s problematic. In other words, there is a difference between something not being studied enough, and something that has been studied and shown to be ineffective. Colorful, stretchy tape falls into that category.

OK, so that’s the executive summary. If you want to take my word for it, then stop reading, however, if you want the details, further down this page I have outlined the proposed, theoretical mechanisms of how this stretchy tape (hereby referred to as KT) works and then listed the research studies that have examined each proposed mechanism.

DOES IT WORK?

To start with, Bassett et al (2010) did a review of the literature up to 2010 and concluded, “At present there is no substantial evidence to support the use and treatment efficacy of KT within a clinical musculoskeletal population.” More recently, Williams et al., (2012) did another review of the literature up to 2012. I will be referring to this review frequently. There are 4 main proposed benefits to using KT:

  1. Supporting the muscle – in terms of strength/endurance
  2. Improved blood and lymph flow
  3. Reducing pain
  4. Correcting joint problems – in terms of increasing range of motion

1. Supporting the muscle – in terms of strength/endurance

Going to the Williams review, they concluded that up to 2012, “there is some evidence for KT having at least a small beneficial effect on strength. However, there was also one unclear and eight trivial results for measurements of strength, which preclude a clear conclusion being made. Further studies on similar muscles, and in particular KTs long-term effect on strength gain, warrant investigation.” Funny they recommended more studies, because since the Williams review, there has in fact, been more studies…and they’ve been negative:

  1. Vercelli et al., 2012 – Took 36 subjects and tested the strength of the quadriceps and single leg hopping. The did 4 trials – one with the subjects taped up to “facilitate” strength, one to “inhibit” strength, one “sham” taping job and one “no” taping scenario. In the end, there was no difference between any of the trials. However, in a post-experiment interview, the subjects were asked if they felt stronger, unchanged or weaker after being taped and 45% stated that they felt stronger when taped. This strengthens the idea of the placebo type of influence that KT provides. The funny thing was that they “felt” stronger regardless of whether they were taped to “facilitate” or “inhibit” the strength. In other words, it doesn’t matter how you put the tape on your skin.
  2. Lins et al. 2012 – Took 60 subjects and tested single hop, triple hop, balance and quadriceps strength. There were 3 groups – one with no taping, one with KT and one non-elastic taping. In the end, they found no difference in hopping, strength or balance with any of the groups
  3. Wong et al., 2012 – Took 30 subjects and taped their quadriceps again and tested the quadriceps strength in taped and non-taped trials. They again found that there was no difference between the taped and non-taped situations. They did find that the taped situation had less time to generate the force.

2. Improved Blood and Lymph Flow

From the Bassett review article: “Support for an improvement in blood flow via KT came from an unpublished study [on the KT website] who found that following KT application, peripheral blood flow, measured via Doppler ultrasound, increased by 20-60% in patients with chronic disorders and poor circulation…. Despite these claimed benefits from KT there is no substantial evidence to support them…. At this time without specific scientific analysis, the perceived physiological benefits of KT are hypothetical

3. Reducing Pain

The proposed mechanism that KT can reduce pain is via stimulating sensory input to the brain, thereby diminishing perceived pain. In other words, if you had foot pain and I kicked you in the knee, you would process less pain from the original foot complaint. This is because your brain can only process so much incoming information at once (aka. gate control theory of pain). In the case of KT, the tape is pulling on the skin which essentially distracts the brain from the deeper, painful structure. When Williams et al (2012) did their review of all the current literature, they found 10 studies that were well designed. Of the 10 studies that looked at KT reducing pain, only one reported a statistically significant difference between the sham and the KT group and even then, the results were “unlikely to be clinically important”.

The one study that KT proponents consistently refer to was a 2008 study by Thelen et al., who found that there was indeed lower pain ratings for those with “real” KT taping procedures compared to the sham group, however the difference between groups was gone within 24 hours after application. The pain reduction quickly abating is likely due to adaptation of the neurologic system. If you’re trying to “trick” the brain into feeling less pain, it quickly adapts to the trick and the pain returns. The authors concluded, “KT may assist clinicians to obtain immediate improvement in pain-free shoulder abduction ROM. However, over time, KT appears to be no more efficacious than sham taping at decreasing shoulder pain intensity or disability.”

The results do show promise however, for those who require something to help reduce pain immediately. For example, if you are a volleyball player in the Olympics and this is something you need to get through a match. However, you also need to consider the consequences: If you are stimulating the skin to help mask the deeper pain originating from damaged tissue, you may be risking further damage to the underlying source of pain.

4. Correcting Joint Problems:

Williams et al., reported that of the 10 studies they looked at, 4 of them found that there were increases in range of motion following the application of KT, however, they were inconsistent and conflicting, “The effect of KT on range of motion remains unclear because of the limited number of studies on a variety of joints, and the conflicting results.” Even in the studies that Williams et al., counted as increasing joint motion, the authors of the original studies were skeptical.

For example, a study by Gonzalez-Iglesia et al (2009) was included in Williams review as a positive study, but the original authors concluded that the “improvements in pain and cervical range of motion were small and may not be clinically meaningful.

Conclusion: Applying this colorful stretchy tape to wherever you hurt may help reduce pain in some small, clinically insignificant way. In a recent journal editorial titled “How Much is Kinesiotaping a Psychological Crutch?“, Vercelli (the researcher listed above) states, “In our opinion, these psychological attributes might help to explain the widespread use of KT by athletes observed during sports competitions“. If you need that, fine, but know that you may be making things worse by masking pain. Also, make sure you get to the root cause of your problem and not just cover it up. In addition, when driving down the road and see your OIL light start blinking…it’s telling you something! Covering it up with KT may block the annoying red light, but you’d better get your car checked out.



Clinicians Billing for Applying Stretchy Tape

NJ based Law firm: “kinesio taping or other taping (which is bundled into the payment for other services) is not reimbursable by PIP and shall not be billed using a strapping code. The only appropriate code to report separately for this service is the cost of the tape from the Durable Medical Equipment Fee Schedule. N.J.A.C. 11:3-29.4(g).”

From Target Coding (a company that helps clinicians bill properly), “I have not read any insurance carrier policies recently that state it will cover Kinesio® taping for alleviating pain, reducing inflammation, promoting good circulation and returning the body to homeostasis. Therefore, you should consider Kinesio® taping a non-insurance payable procedure….We do not recommend you billing CPT codes 29200, 29240, 29260, 29280, 29520, 29530, 29540 or 29799 for Kinesio® taping. In my opinion these Casts and Strapping codes are meant to “immobilize” a joint or body part and are therefore should not be used for Kinesio® taping. Also, we do not recommend you bill CPT codes 97110 or 97112 for Kinesio® taping.”

CPT® Assistant, March 2012, states that “Kinesio taping is a supply and therefore is included in the time spent in direct contact with the patient to provide either re-education of a muscle and movement or to stabilize one body area to enable improved strength or range of motion. This includes the application of Kinesio tape or McConnell taping techniques.”

American Chiropractic Association: “As such, when applying Kinesiology Taping to a patient in conjunction with another therapy, the Kinesiology Taping service should not be separately reported. It is not appropriate to code 97110 or 97112, etc. if kinesiology taping is the only work performed. The only appropriate code to report, in addition to the therapy service rendered, would be the supply code for the tape itself, either A4450 Tape, non-waterproof, per 18 sq. inch or A4452 Tape, waterproof, per 18 sq. inch.”

Break Down of Energetic Cost for Each Component of Running

About a month ago at the Running Medicine Conference at the University of Virginia, I had the pleasure of listening to a presentation by Rodger Kram, PhD; a researcher at the Locomotion Lab at the University of Colorado. Life has been busy lately so it’s taken me a while to get around to writing this. (Thanks to Dr. Kram for permission to use pics and reviewing this for me before I posted it)

Dr. Kram frequently publishes research papers in journals but the topic of his presentation at the Running Medicine Conference was on “Disintegrating the Energetic Cost of Running”. In this case, disintegrating means to break down into its smaller parts. Basically, through a number of different studies, he and his students and colleagues have been able to look into how much each different task of running costs us – energetically speaking.
Table 1 outlines the basic major components of running:

table1

In order to find out what the energetic cost of each component of running was, Dr. Kram and his grad students would measure various runners to find out what their energy consumption was normally, then invent some sort of apparatus to eliminate the energy cost of each of the factors listed in table 1. So, for example, to eliminate the energy cost of body weight support, they constructed this apparatus:

Body weight picture

They found that as they progressively offloaded the vertical component of body weight, the runners used about 26% of the energy compared to when they had to run with 100% of their body weight. In other words, holding up your body weight accounts for 74% of the energy of running. The study is found here.

In another study, they eliminated the cost of forward propulsion by fabricating this gizmo:

Forward Propulsion

They found that by eliminating the work needed to propel the body forward, the runners used up to 41% less energy. In other words, 41% of the energy for running is used for forward propulsion. The study is found here.

To eliminate the energy needed to swing the leg forward for each stride, they constructed this:

leg swing assist

They discovered that the action of swinging the leg forward for each stride accounted for about 20% of the energy cost of running. The study is found here.

Now, if you’ve been paying attention up to now, you should have realized something.

clip_image002[4]

Obviously, there is a problem when you have just a few of the components add up to 135%. As Dr. Kram explains, that is due to synergy. In other words, there is a cooperative action of two or more movements, muscles, nerves, fascia etc.

In order to see how much synergy there was in these three tasks, they combined the vertical body weight support, the forward propulsion and the leg swing assist all in one contraption rivaling the Death Star:

All combined assistance

They did a bunch of trials with different combinations and eventually figured out that because of synergy, the vertical body weight support, forward propulsion and leg swing accounted for 87% of the energy used for running. The study is found here.

table with 3 combined

Next on the list was arm swinging. In this case, Dr. Kram had a different hypothesis. The way he figured it, swinging the arms actually assists the energy of running by counter-rotating the upper body. If we didn’t swing our arms, it would cost more energy to run. So, they ran normally, then with the arms behind the back, folded across the chest and hands clasped behind the neck.

no arm swing running

In the end, they found that they were correct – eliminating the arm swing increased the energy cost by about 4%. The study is found here.

table with arm swing

At that point, Dr. Kram and his grad students came up with a bizarre notion: Since the arms weigh about 10% of the body weight, and propelling the body weight forward and lifting it vertically costs energy, it costs a certain amount of energy to have the arms on your body. Since swinging the arms saves 4% of the energy cost, but the weight of the arms costs you about 9% of your energy, you could potentially save about 5% of your energy by amputating your arms. So, they paid a grad student…….just kidding!

Moving on, Dr. Kram and colleagues have assumed that running with the feet narrow, (not zero width or cross-over) costs less energy and helps balance when compared to running with a wider base. So, they had runners run on a treadmill with varying step widths and measured oxygen uptake again:

step width

In the end, they found that when runners ran with the feet at widths less than or greater than their preferred step width, there was greater metabolic demand. In other words, they concluded that step width costs zero energy. This could be based on the idea that running with an unfamiliar gait pattern increases metabolic cost. The study is found here.

table with step width

The next factor for energy cost was balance. Balance competency is highly variable. We use this as a movement screening tool in our office and it’s surprising how come runners are unable to perform a single leg stance for more than a few seconds. They are moving their arms around, the foot is moving all over the place and then they have to put the other foot down. Well, how much energy does it cost in running to simply balance yourself? To answer that, Dr. Kram and colleagues hooked runners into the following contraption:

Lateral stabilization picture

Pretty simple apparatus, yet ingenious really. They developed something that stops lateral swaying, yet allows the runners to swing their arms freely. After measuring the metabolic cost without the apparatus and then with it, they found that there was about a 2% energy savings when the apparatus was used. That is to say, balance when running on a very flat surface constitutes 2% of the total energy expenditure. It may be greater when running on trails or uneven terrain. The study is found here.

To summarize up to here, we have the following table:table with balance

So, next on the agenda is shoes. Obviously a contentious topic these days. At this point of his presentation, Dr. Kram recapped a 1984 study in which found that for every 100 grams of shoes weight, there was a 1% increase in metabolic cost. However, there are many other studies that have not reproduced these results; for better or worse:

shoe energy costs from different studies

This may be because when compared to shod running, barefoot running reduces energy cost due to less weight on the foot, OR, running barefoot increases metabolic cost due to a lack of shock absorption. Nobody knew for sure. So Dr. Kram’s student team set out to find the answer. They performed a number of trials with subjects running barefoot or shod, plus running barefoot or shod with 150, 300 or 450 gram lead strips attached to the barefoot or shoe. When they measured O2 intake and CO2 production and calculated metabolic cost, they discovered that when given equal mass between barefoot or shoes, shoes save 3-4% in metabolic power. WHY? Well, we don’t know for sure, but the hypothesis is that shoes provide shock absorption and without it, your legs have to absorb the shock. Absorbing shock with your legs costs energy. Study found here.

table with shoes

So, the best case scenario is as follows: find the lightest shoes that provide ample cushioning (from an energy perspective) Why is that? Well, because as they found out, mass is bad but cushioning is good…to a point (as you will see below).

In this last study that Dr. Kram discussed, they wanted to measure the energetic costs of the surface you run on. To accomplish this, they used a very rigid surfaced treadmill with a steel deck and no give. Then they put slats of foam that are used for shoe cushioning and modified the treadmill to look like this:

foam cushioned treadmill

The researchers had experienced barefoot runners run on the hard steel deck, and then run barefoot with 20mm of cushioning, then with 10mm of cushioning. What they found was there was a sort of “sweet spot” of cushioning for reducing metabolic energy. 10mm was better than no cushioning, but 20mm was too much cushioning and energy expenditure increased.

The surface you’re running on can vary energy consumption greatly. For example, Lejeune et al., (1998) found that running on sand costs an extra 60% compared to running on a hard surface, yet Kerdok et al., (2002) found that with the right amount of compliance, the surface can actually decrease energy consumption by as much as 12%.

table with final combined

So, the surface you’re running on could be one of the highest costs of energy when running, or could actually decrease the cost of energy.

That concluded the end of Dr. Kram’s presentation, but he left us with some thoughts….

  1. They can’t account for 100% of metabolic costs of running because there are so many variable factors.
  2. You can account for nearly 90% of the metabolic costs with 3 factors: vertical body weight support, forward propulsion and leg swing
  3. Arm swing actually saves energy, shoes don’t make that much of a difference, but surfaces can make a huge difference
  4. There are many factors that can account for the total metabolic costs such as the horizontal braking forces, ventilation (breathing), cardiac work, and decelerating and reversing the forward leg swing, they just haven’t developed a way to measure those factors yet

 

Femoral Anteversion, Craigs Test and Poor Advice

The intent of this article is to shed some light the idea that decisions are not black and white when it comes to health. More specifically, this article is about lower extremity joint coupling. I hope that it is easy enough for non-healthcare folks to understand, yet detailed enough for healthcare providers to reference.

Essentially, I’m getting frustrated with patients coming into the clinic and telling me they received a gait analysis, or a bike fitting from someone with zero anatomy education but a self-perceived wealth of healthcare advice.

The impetus and motivation to write this article stems from a patient encounter a couple weeks ago. She is a triathlete with pain when she runs and bikes. Recently, she had a bike fitting and the bike fitter told her that her knee was tracking inward (toward the top tube) when she biked and she should make a conscious effort to force her knee outward at the top of the pedal stroke. There was also talk about putting a varus wedge between the cleat and the shoe to help force the knee straighten out. (Not only did he say that, but also that the knee was going inward because the ITB was too tight and she needed to stretch it…?)

Sorry if I’m stepping on toes here, but my opinion is that in a situation like that, the bike fitter should be sticking to properly fitting the bike to the person rather than dispensing treatment advice and modalities. I’m all for bike fitters helping performance, but if someone has pain, I think there may be some boundaries that are crossed if they are prescribing stretches or installing orthotic wedges. The same goes for those who are doing gait analysis on runners.

During my office examination with this patient, I did a standard procedure that I do on many patients: Craig’s test to check for femoral versions. This patient did have significant femoral anteversion (explained below in the video). This femoral anteversion explains some of the knee tracking inward and it reminded me of why people without any anatomical or biomechanical education should be cautious about dispensing therapeutic advice.

What is Craig’s test and femoral anteversion? Below, I have made a video explaining femoral versions/torsions and Craig’s test (how to easily screen for them). I have to used this video occasionally for clients of Running Reform. When clients submit their video to me and there are significant rotational distortions in their lower extremity, I ask them to perform this test at home and report back. Ruwe et al., (1992) proved this test to be more reliable than CT scan and I think it’s pretty easy to perform.

Please watch the 3 minute video here which explains a lot more than just Craig’s test:

Since femoral anteversion causes internal rotation of the femur and internal rotation of the femur is associated with greater knee valgus, one could assume that femoral anteversion is associated with knee valgus.

Figure 1: Running form with knee valgus

This idea makes sense and has been proposed by Hvid et al., (1982) and by Nguyen et al., (2007). However, Nguyen et al., (2009) used Craig’s test to evaluate femoral version and found no relationship to knee valgus which contradicts the previously listed studies. However, they tested knee valgus in a static double leg stance and this doesn’t mean that there would not be any dynamic valgus. In other words, standing still may not have increased knee valgus, but when running, jumping biking etc., there may be increased knee valgus in those with femoral anteversion. This is due to a couple reasons:

  1. Merchant (1965) that the gluteus medius is at a mechanical disadvantage in those with femoral anteversion. Basically, the lever arm is reduced. Since the gluteus medius is important for maintaining frontal plane stability of the hip and knee (not allowing the hip to adduct or the knee to collapse inward).
  2. Nyland et al. (2004), showed there is decreased activation of the gluteus medius, as measured by surface electromyography amplitude, in people with increased relative femoral anteversion.

When you put these together (reduced mechanical leverage plus reduced activation) it suggests that those with femoral anteversion would have a tendency to have increased dynamic valgus at the knee.

There are suggestions that femoral anteversion increases anterior knee pain most likely due to patellofemoral pain – Eckhoff et al., (1994) and Eckhoff et al., (1997). In addition, Takai et al., (1985) and Eckhoff et al., (1994) found increased arthritis in the patellofemoral joint was associated with femoral anteversion.

Moving on from femoral anteversion to femoral retroversion…When patients talk about getting a “knee replacement”, they are usually talking about arthritis in the tibiofemoral joint. This type of arthritis is generally on the medial (inside) compartment as it is usually prone to develop arthritis. Therefore, a patient at risk of this (family history, cartilage degeneration etc.) should be wary of anything that places extra pressure on the medial compartment. There are studies that show femoral retroversion increases the pressure on the medial compartment of the tibiofemoral joint. Bretin et al., (2011) not only showed that femoral anteversion predisposes the knee to a valgus deformity but also that femoral retroversion predisposes the knee to a varus deformity and also increases the pressure in the medial tibiofemoral joint. Kenawey et al., (2011) confirmed this notion by reporting that the medial tibiofemoral joint increased it’s pressure by nearly 30% when there was 20 degrees of femoral retroversion compared to anteversion. Again, Papaioannou et al., (2013) confirmed the increased compression medial compartment of the knee joint due to femoral retroversion.

So, if femoral retroversion is susceptible to knee joint pain and arthritis, and femoral anteversion is susceptible to patellofemoral pain and arthritis, everyone should be trying to force the knee straight, right? Not so fast. If a person with either retro or anteversion tries to rotate the leg so that the toes are pointing straight, the result may not be what you want. Essentially, the person is being asked to force the hip into a position where the head of the femur is no longer seated properly in the acetabulum which could lead to hip joint pathology. There are no studies that have evaluated this, but logic has to take over at some point. In his book Human Locomotion, Michaud states, “Unfortunately, once the femoral anteversion has been formed, attempts to modify an individual’s gait by having him/her walk with a straight gait pattern decreases the mechanical efficiency of the gluteus medius musculature and increases femoroacetabular contact pressures.”

Unfortunately, in many cases a person with femoral anteversion or retroversion will wrongly be instructed to keep their knee straight, or point their toes forward. They may be given a varus or valgus post in their running shoes or bike cleats to try and “straighten things out.” This can potentially be detrimental, since they essentially are being instructed to lose congruency in the hip socket which would increase contact pressures and risk potential injury.

So, as usual, the answer to this and many other conditions of the body is “it depends.” You can’t absolutely state with 100% confidence that a person with their knee going in toward the top tube should be forcing it to go straight via conscious efforts or with a cleat wedge. Then again, you can’t absolutely state with 100% that they shouldn’t either! Femoral versions need to be considered, tibial torsions need to be considered (perhaps in another blog post), patient genetic susceptibilities need to be considered, movement patterns need to be evaluated, patient symptoms need to be considered and the list goes on. Despite this, there will still be people with zero knowledge of biomechanics or anatomy dispensing advice with way more confidence than I have, even after I have considered the information above.

Will they guess correctly? Roll the dice and find out!

 

Pain Leads to Dysfunctional Movement and Vice Versa

You can’t put fitness on dysfunction.” – Physical Therapist, Gray Cook

Injury prevention and injury therapy are both shifting from focusing on regional anatomy to more of a global movement appraisal and correction. For example, if a patient suffers from tennis elbow, treatment used to focus on the elbow. Up to date clinicians these days will focus more on appraising and correcting faulty movement patterns that may be happening in different part of the body (in the shoulder and thoracic spine for example) which may be the reason the tissues in the elbow became overstrained. This article focuses in on how pain can cause dysfunctional movement and how dysfunctional movement can cause pain. The central nervous system’s role in this cannot be understated. Below, I have given a few of the very interesting studies and examples that are emerging.

Ok, here’s a little 3 question test:

  1. Guess what the best predictor of low back pain is? Weak abdominal strength? Being slightly overweight?
  2. Guess what the best predictor of hamstring strains is? Leg length difference? Short, tight hamstrings?
  3. Guess what the best predictor of running injuries is? Lack of orthotics? Running on hard surfaces? ‘over’pronation?

If you answered “yes” to any of those, sorry, but you’re way off. I actually put those up there because those are all factors that have been shown to NOT be risk factors, or very weak risk factors at best. Nope, the biggest risk factor for low back pain is: Previous low back pain [1]. The biggest risk factor for a hamstring strain is: Previous hamstring strain [2]. The biggest risk factor for a running injury is: Previous running injury [3].

What that ultimately means is that the underlying cause of the injury has persisted in each one of those situations I listed above and recurrences become the norm.


Why am I telling you this? Two reasons I suppose:

  • First, our current method of applying treatment to the area of pain is incomplete, narrow minded and simply doesn’t work because it doesn’t help fix the underlying problem and will likely lead to recurrences.
  • Second, and more importantly, because I’m trying to bring some awareness to the idea that pain leads to dysfunctional movement and dysfunctional movement leads to pain. This is a peek into the mechanism of recurrent injuries.

As an illustration, let’s look at just one example: Recurrent ankle sprains. Guess what the biggest risk factor is? If you guessed previous ankle sprain, you’re right [4].A 2006 study [5] found that people who suffered from chronic ankle sprains also exhibited weakness in the hip muscles on the same leg as the chronic ankle sprains. There is nothing new to this. We know from many different studies that individuals with ankle sprains also suffer from poor motor control in the hip [6,7,8,9,10]. The link between faulty hip movement and ankle sprains has been well established, but what is the significance?

I think you have two options:

  1. There is an inherent motor control problem in the hip which results in poor motor control for the leg and ends up with recurrent ankle sprains, or…
  2. The person suffered an ankle sprain which set off a chain reaction of neurologic/movement compensations and resulted in poor motor control of the hip and pelvis.

More succinctly, the two options are: 1) Did the poor motor control in the hip cause the ankle sprain, or 2) Did the ankle sprain cause the hip problem?

Researchers aren’t really sure of the answer yet, but we have some clues. With the use of EMG, researchers can measure exactly when muscles turn on and off and thereby map out the brain’s strategy for moving a limb. We can call this the “muscle firing pattern”. When laying face down and asked to lift the leg upward (see figure 1), normally we would expect to see the low back muscles, glutes and hamstrings do the work in lifting the leg. The exact order of which muscles fire in the pattern is not consistent between people, but should it should be consistent in the same individual?

Figure 1. Illustration of Prone Leg Extension

A recent study looked at the muscle firing pattern of healthy people performing this test. Serendipitously, 10 weeks following the test, one of the subjects sprained her ankle while “leaping into a camping tent filled with children”. When she came into the clinic 2 weeks later for treatment of her ankle sprain, the researchers had her perform the prone leg extension test again. They found that the low back muscles fired much earlier in this subject than they had before she sprained her ankle [11]. 8 weeks later, when her ankle was healed, they did the test again and the low back muscles fired even earlier than they had 2 weeks after the ankle sprain.

In other words, following the sprained ankle, her brain changed its strategy for hip extension. The timing is laid out in Figure 2.

Figure 2. Times are in milliseconds and are listed relative to then the hamstrings contracted. Positive numbers indicate the muscle contracted after the hamstrings, negative numbers indicate the muscle contracted before the hamstrings

So, what does this teach us? Well, frankly not much because it was only one subject, so we can’t start making blanket statements. However, it is one example showing that pain can lead to altered movement strategies and those altered movement strategies can persist after the pain is gone. It’s an example of how the brain can “re-map” a motor pattern.

Moving on, we can look at another article published in 2012 which reviewed all previous research on the most common running pain: patellofemoral knee pain. In this review article, the researchers determined that in people suffering from this type of knee pain, there was consistency in the research showing delayed and shorter duration contractions of the gluteus medius muscle in the hip compared to people without the knee pain [12]. Again, this doesn’t show a cause and effect, just a relationship. However, it once again shows that pain and dysfunctional movement patterns are interrelated.

There is one last study I would like to highlight and this one is on knee extension and anticipation of pain. I think most people would agree that your brain will likely alter the movement strategy for the muscles that move a painful joint. In other words, if you have pain, you will recruit muscles differently than if you didn’t have pain. Unfortunately, researchers have also proven that when you ask people to generate an extension force with the knee, the brain recruits muscles in a particular order and intensity that is the same whether the person feels pain or even if they anticipate pain [13]. In other words, in a non-pain vs. pain situation, we move differently, but in a pain vs. anticipation of pain situation, we move the same. That means that all you have to do is convince someone that they will feel pain in a joint and “presto”…they will now move differently simply by anticipating pain.

This has huge implications for rehabilitation because it becomes so much harder to get patients to move correctly when they have had chronic pain. Even if the painful source is eliminated, the brain can still be capable of anticipating pain and so the patient has a hard time overcoming the movement problem. Not overcoming the faulty movement pattern may lead to altered loads on the rest of the body and possibly persistent or recurrent pain.

To summarize, our neuromuscular system is more complex than we give it credit for. When you suffer from recurrent hamstring strains, tennis elbow, low back pain etc., there is a reason for it. It’s not just weakness. It’s not just tightness. It’s not just a build up of adhesions and scar tissue. It’s not just trigger points. Our motor control, timing, coordination, movement patterns, stability and a host of other factors play a role in determining how we move and why we get injured. An appraisal of how you move is the bare minimum of what your should expect from your health care provider and if they are focusing only on the site of pain, don’t expect fantastic outcomes.

“He who treats the site of pain is lost.” – Karl Lewit

1. Balagué F, Mannion AF, Pellisé F, Cedraschi C. Non-specific low back pain. Lancet. 2012 Feb 4;379(9814):482-91.
2. Árnason Á, Sigurdsson S B, Gudmundsson A. et al Risk factors for injuries in football. Am J Sports Med 2004. 32(suppl 1)S5–16.16.
3. Buist I, Bredeweg SW, Lemmink KA, van Mechelen W, Diercks RL. (2010). Predictors of Running-Related Injuries in Novice Runners Enrolled in a Systematic Training Program: A Prospective Cohort Study. Am J Sports Medicine, 38(2):273-80.
4. de Noronha M, França LC, Haupenthal A, Nunes GS. Intrinsic predictive factors for ankle sprain in active university students: A prospective study. Scand J Med Sci Sports. 2012 Jan 20
5. Friel, K., McLean, N., Myers, C., & Caceres, M. (2006). Ipsilateral Hip Abductor Weakness After Inversion Ankle Sprain. Journal of Athletic Training. Vol. 41 No.1, 74-78
6. Bullock-Saxton J. Local sensation changes and altered hip muscle function following severe ankle sprain. Phys Ther. 1994;74:17–28.
7. Freeman MA, Wyke B. Articular reflexes at the ankle joint: an electromyographic study of normal and abnormal influences of ankle-joint mechanoreceptors upon reflex activity in the leg muscles. Brit J Surg. 1967;54:990–1001
8. Sadeghi H, Sadeghi S, Prince F, Allard P, Labelle H, Vaughan C. Functional roles of ankle and hip sagittal muscle moments in able-bodied gait. Clin Biomech (Bristol, Avon). 2001;16:688–695.
9. Nicholas JA, Strizak AM, Veras G. A study of thigh muscle weakness in different pathological states of the lower extremity. Am J Sports Med. 1976;4:241–248.
10. Bullock-Saxton JE, Janda V, Bullock MI. The influence of ankle sprain injury on muscle activation during hip extension. Int J Sports Med. 1994; 15:330–334.
11. Lehman GJ. Trunk and hip muscle recruitment patterns during prone leg extension following a lateral ankle sprain: A prospective case study pre and post injury. Chiropr Osteopat. 2006 Feb 27: 14:4
12. Barton CJ, Lack S, Malliaras P, Morrissey D. Gluteal muscle activity and patellofemoral pain syndrome: a systematic review. Br J Sports Med. 2013;47:207-214
13. Tucker, K., et al, Similar alteration of motor unit recruitment strategies during the anticipation and experience of pain, Pain. 2012 Mar;153(3):636-43. Epub 2011 Dec 29.

Flattered:1st Specialized Running Clinic in USA

Active Spine and Sport has been chosen as the 1st “Specialized Running Clinic” in the USA by TheRunningClinic.com.

TheRunningClinic.com is an organization in Canada that was founded and operated by Blaise Dubois, a physiotherapist in Canada. He teaches different courses at the University level in Canada, published research in clinical journals and worked with the Canadian Track & Field team. TheRunningClinic.com performs continuing education conferences for running injuries and gait analysis around the world.  You can see the list of their conferences here.

I had the pleasure of meeting Blaise a couple years ago and occasionally consult with him on various topics through email.  Through these contacts, my blog posts and twitter posts, we have built a professional relationship and Blaise has become aware of what we do in our clinic and what I am doing with RunningReform.com.  It was through these conversations that, a couple months ago, Blaise invited me to become the first “specialized clinic” listed on their website for the USA.  We are quite honored to be named into this group of specialists around the world


Currently, the TheRunningClinic.com has recommended clinics in Canada, Australia, France, Spain and the UK by designating them as Specialized clinics.