10 key points to perform and stay an injury-free runner

Here are the different points most runners want to consider in order to increase their performance while minimizing the odds of getting injured.

1. The majority of runners sustain an overuse injury over a 1-year period.

2. Chose dynamic stretches over static stretches before a run. You want to increase your body temperature.

3. Knee pain is the most common area of complaint with runners. It often relates to a problem at the ankle and/or the hip.

4. In most cases, improving ankle mobility and increasing gluteus muscle strength is beneficial. Quadriceps, hamstrings, and hip external rotators are important muscle groups to strengthen, too.

5. Hamstrings are the most important muscle to stretch/improve flexibility.

6. Pick the most comfortable shoes you can try. Do not choose a model that will accentuate your natural foot type. Flat feet? Motion-control shoes should feel better. High arch? Try cushioning/neutral. Minimalist shoes are not the go-to/best available option. It is a valid option that requires a careful and progressive transition.

7. Gait retraining is a good option to increase performance while preventing pain.

8. Foot orthotics can help to control symptoms in acute pain phases.

9. Anatomical “issues”, like asymmetrical leg length or misaligned pelvis, have little impact in comparison to muscle imbalance. Focus on getting stronger.

10. Reduce the volume of running when you sustain an overuse injury. Try 50% first.

This is a generic list, so you do not have to necessarily focus on each and every aspect described. Some might be more beneficial to you than others, depending on your running and fitness level.

For some more specific advice, feel free to book an appointment with one of our experienced physiotherapists.

Key points of a runner’s knee clinical assessment

A non-traumatic knee problem is, most of the time, linked to something happening upstream - the hip - or downstream - the ankle.

To keep it fairly simple, let’s simplify the knee assessment to the way the legs look in a standing position.

 

Excessive knee abduction - knees are close to each other / legs look like an “X”.

 

  • This can be linked to reduced strength of the following muscles: gluteus medius and hamstrings.
  • Hips and knees can be internally rotated, and we observe an opposite side pelvic drop.
  • The foot can show over-pronation / “too flat”

 

For reduced knee abduction - knees are far from each other / legs look “brackets”.

  • No proved links with muscle strength issues.
  • The other 2 parameters are opposite to the previously described mechanisms.

 

In our next post, we will try to summarize the key information from the previous weeks posts.

 

There are definitely common patterns runners are facing. We can try to work on these in order to prevent injuries and increase performance.

HKSC - Running injury

Can runners’ gait be effectively re-trained?

Running mechanics have often been cited as potential causes for running-related injuries.

It is believed that altering one’s mechanical pattern may lead to reduce the loads on tissues and joints.

Altering your running technique is not an easy task, as locomotion is thought to be pretty much automatic and difficult to change.

There are 2 main things you can focus on to modify your gait: using feedbacks - visual or real-time -, or training some key muscles.

For visual feedback, our modern age makes tablets like ipads accessible. They can be used instead of a mirror to give you a precise vision of your running technique. Put some markers on the key areas to focus on, and you are all set.

For real-time feedback, the setup is trickier as you need both devices on your body, and a monitor to tell you instantaneously what is happening.

Even though studies are not legion, the existing ones are positive about feedbacks effectiveness.

A common aspect of many running-related injuries is a weakness of certain key muscles, like glutes, hamstrings, or tibialis posterior. Identifying the culprit may lead to a “natural” resolution of the poor running technique.

Combining both visual feedbacks with strength training seems to have the highest potential to improve gait patterns and reduce pain.

 

Hip to foot relationship and running injuries

Torsional forces commonly happen during running, and their increase is believed to be associated with higher injury risk.

The measure of such forces during the stance phase of the gait is called the free moment.

Free moment can be described as the resistance to toeing out when the foot is fixed to the ground.

For instance, higher free moment has been reported to be leading to a higher risk of tibial stress fracture.

An externally rotated foot - overpronated - can increase the free moment, too. This is often linked to modifiable factors like reduced hip internal rotation, or hip external rotators strength. Nonmodifiable factors include femoral head anteversion.

Measuring the free moment requires specific equipment, like a force plate. If you do not have access to this, we can identify flaws in the kinematic chain by filming you running on the treadmill.

The hip anatomical alignment and flexibility

There are very few scientific proofs about the reliability and validity of hip and pelvic alignment measures. A longer or shorter leg has often been pointed out as having an impact on biomechanics and joint injury.

From the literature, a leg length discrepancy - LLD - has to be over 20mm, measured on an X-ray.  In reality, we do not see many LLD over 15mm. The association with the injury-rate remains unclear to this day.

The important movement for a runner’s hip is internal rotation. It requires enough motion to avoid stress on the different downstream joints.

Unfortunately, few studies have investigated the role of hip rotators' strength on musculoskeletal injuries.

Hypermobility of the hip rotators can sometimes be associated with knee pain, because of atypical biomechanical motion.

The IT-band, on the outside part of our thigh, seems to be influenced by both over-pronation at the foot, as well as reduced hip abductors' strength.

HKSC -

Hip strength and running injuries

The first 20% of the stance phase - from landing to toes-off - relies predominantly on our quadriceps and gluteus muscles. They prevent the knee and hip from collapsing when the knee bends. The two muscle groups help us to maintain balance and not fall forward/laterally.

During the midstance, gluteus muscles remain active, while stability also comes from more passive structures, like the hip capsule and various ligaments. The hip extension sees the hamstrings kicking in, too. 

Given how active the gluteus medius is to help with overall balance, many studies hypothesized its weakness may contribute to running-related injuries. 

People with patellofemoral pain syndrome seem to have reduced gluteus medius strength, which results in a hip drop at foot impact. The exact mechanisms on how this impacts hip and knee biomechanics remain unclear.

To sum it up, if you want to improve your running performance and try to stay injury-free, training your gluteus muscles - the gluteus medius in particular - is never a bad idea.

Assessing hip mechanics for runners

Over the past 20 years, the hip joint has been focused as a key injury predictor.

When the knee flexes, internally rotates and abducts during the first half of stance, the hip works in a similar fashion.

After heel strike and during the first third of the stance the hip flexes then undergoes almost full extension for the remaining two-thirds, until toe-off.

Comparatively, the hip does 3 to 4 times less internal rotation than the knee. External rotation of the hip starts at about 20% of the stance phase. Hip adduction then abduction happen with each phase.

Just like the relationship between the knee and the rearfoot, the hip and the knee work in an asynchronous way.

One of the reasons the knee gets injured so often at running is that both the knee and the ankle rotate faster and to a larger degree than the hip. The knee becomes a “logical” place of injury even under normal biomechanical circumstances, being in the middle and affected by any problem occurring downstream or upstream.

Next post we will talk about the potential impact of hip strength on runners.

The importance of our knee muscles flexibility

There is a hole in scientific research when assessing our knee muscles. While the quadriceps and hamstrings have been studied quite extensively, others, like the IT band, our adductors, and sartorius have an unknown contribution to the gait mechanics.

The flexibility of the hamstring - the back of our thigh - seems to be critical for injury prevention.

The load on the hamstring increases during the swing phase, when the knee extends. The lateral part of the muscle undergoes the most load.

A tight hamstring has a similar negative impact on our gait - shortened stride length, reduced knee flexion at heel strike - as a weak muscle. The average hamstring flexibility during a single leg raise revolves around 70-75 degrees.

A previous injury does not seem to affect our hamstring’s flexibility.

Despite several studies, no conclusion could be made for the quadriceps muscle.

In conclusion, muscle flexibility is not the most important factor to injuries but has its place in the global puzzle.

Next post we will start talking about the hip joint.

The anatomical alignment of the knee

It has been discussed for a long time that our pelvis/hip structure may influence the running-related injury rate.
 
An increase of the Q-angle - the angle between the femoral bone and a vertical line - has often been described as a risk factor, putting more load on the outside part of the kneecap. Science does not really support the negative impact of the Q-angle on our lower-body biomechanics.
 
As this is a factor that cannot be modified anyway,reviewing the role of our muscle flexibility seems to make more sense.
 
So basically, the shape of our body - think hips, pelvis and spine - does not define nor predict our risk for getting injured while running.
 
Several muscles that cross the knee joint have not been heavily discussed in regard to their role in the gait mechanism.
 
Hamstrings and quadriceps, on the other hand, have been studied pretty extensively.
 
These will be highlighted within our next post.

A basic knee muscles overview

Several muscles cross the knee, to provide dynamic control and stability.

Hamstrings and quadriceps are key muscles with our gait. The main reason being most of the movement happening in a sagittal plane.

The first group of muscles acts during the swing phase, for an eccentric control of our knee extension. It prepares for the heel strike. Weak hamstrings reduce our hip extension at toe-off. 

During the stance phase, the hamstrings stabilize the knee, maintaining the best position of the tibia relative to the femur. They can also be seen as dynamic synergists to our ACL, preventing anterior translation of the tibia and reducing shear forces on the ligament.

During the stance phase, they do overall less than our quadriceps. You still need strong hamstrings for both take-off and landing, basically. 

The side parts of our quadriceps, or vastus medus and lateralis, are very active throughout most of the midstance. 

Other muscles help to stabilize transverse - side to side - planes of motion of the knee.

As in many other circumstances, the weakness of one group relative to the other will create an imbalance in muscle use, potentially leading towards overuse injuries.

Joseph March
Founder and Physiotherapist

After graduating from university in Australia, Joseph had solid exposure in a wide range of areas including professional sports, neurological, pediatrics, gerontology, and rehabilitation.

Joseph has over a decade of experience in Hong Kong, specializing in rehabilitation of musculoskeletal and sports injuries. He has treated issues related to pregnancy, desk jobs, as well as the unique injuries that come with a variety of athletic pursuits.

He has partnered with the Hong Kong Football Club as the performance squad physiotherapist, as well as the Hong Kong Ballet as the consulting physiotherapist.

Joseph’s hobby outside of work is the pursuit of a better functioning body. This has led him to delve deeply into many types of exercise and performance training. He has years of experience in Olympic weight lifting, movement training, powerlifting, yoga, pilates and strength, and conditioning. Through his own journey, Joseph has positioned himself well to understand other bodies and across a wide range of exercise and sport.

In the past Joseph competed at a high level in football and long distance running.

Cardeux Nel
Senior Physiotherapist

Cardeux represented South Africa and attained her first karate world championship medals at the age of 11. Cardeux’s other sport of interest is field hockey, which she has also played at a national level. From a young age, she attended physiotherapy to enhance performance and recovery. Understanding the importance of this stimulated her to pursue a career in helping others.

After graduating from The University of The Free State in South Africa, Cardeux spent a few years working in private practice as well as gaining experience in sports physiotherapy. She assisted with the Springboks in the lead up to the 2015 Rugby World Cup and worked at the Comrades Marathon for 4 consecutive years.

Cardeux’s treatment is focused on exercise, education, and a holistic therapy approach. As a keen trail runner, she specializes in performing full running assessments, both clinical and video. She has also completed her post-graduate course in Dry Needling which she provides as part of her treatments.

Cardeux spends her time off continuing to pursue sports-related endeavors. She is captain of the Valley Premier women’s field hockey team, coaches running, and manages the Hong Kong Sports Clinic running team. She also extends her passion for the sport by giving back, as a member of WISE HK – Helping empower, educate, and connect women and girls through sport in Hong Kong.

 

Pronouns: she/her

Elaine Leung
Principle Chiropractor

Elaine completed her chiropractic training at Macquarie University in Sydney, Australia with a Bachelor’s degree in Chiropractic Science and Master’s degree in Chiropractic. She then moved to Hong Kong to pursue her career and to promote the importance of health and the work-life balance.

Coming from a family of martial artist and traditional Chinese lion dancers, Elaine also developed an interest in Muay Thai, BJJ and weight training. This of course also comes with some injuries which have always been managed with chiropractic.

Her long interest and love for animals have then lead her to complete a Certificate in Animal Chiropractic in the USA to enable her to provide care for animals as she does for people. She is passionate about getting people (and animals) out of pain and living their lives to the fullest.

Emma Piachaud
Senior Physiotherapist

Emma returned ‘home’ to Hong Kong in 2011 after having spent her childhood here. She completed her Bachelor’s Degree (Hons) in Physiotherapy in the UK and has subsequently worked in the UK, France, and Hong Kong in a variety of settings, including the National Health Service, private hospitals and clinics, and a ski resort.

Emma is a keen sportswoman, which has led to a natural interest in sports injury rehabilitation and exercise-based therapy where she has completed many postgraduate courses specialising in manual therapy and core stability retraining. These have been in areas such as the lumbopelvic complex and thoracic rib cage and their combined effects on the musculoskeletal system. She has used this knowledge when treating clients, from elite athletes with chronic overuse injuries to postnatal women returning to sport.

Emma is available to assess and manage all musculoskeletal conditions including neck and back pain, sports injuries, thoracic and ribcage issues, and post-surgical rehabilitation. In addition, Emma has a specialist interest in treating specific problems related to ante and post-natal women, including pelvic girdle pain, rectus diastasis, mastitis, and assisting in return to sport and fitness.

Katia Kucher
Principle Nutritionist

Katia is a nutritionist with a Precision Nutrition certification and NASM Sports nutrition certification. Katia has also been a fitness, road, and trail running coach for many years. Her focus is on finding the ideal personalized diet plan to maintain a healthy lifestyle. Her other certifications include NASM Personal Trainer, PTA Global Personal Trainer. She also does corporate talks and presentations about nutrition and fitness.

As a nutritionist, her goal is to create a personalized nutrition plan and diet to help clients reach their health and fitness goals, or resolve any health issues. The key is to find a healthy, balanced, life sustainable diet that is adaptable to the client’s body type, metabolism, and lifestyle. For athletes, she creates nutrition programs to improve their performance, strength and endurance levels, and promote faster recovery.

Her background also includes helping clients dealing with injuries, by recommending a diet and specific foods that follow the healing phases to help with the healing quality and speed.

If you find it challenging to find a proper diet that will help you reach any of your goals, Katia can help you achieve your goals or help with any health issues, by recommending a diet you will enjoy and be able to maintain.

Taras Makarenko
Principle Osteopath

Taras is the Principal Osteopath with the Hong Kong Sports Clinic, where he specialises in mechanical pain associated with sports injuries, “desk-bound” related back pain, and nerve entrapment syndromes, like sciatica pain.

He has post-graduate training in both pre and postnatal as well as infant and newborn treatments. His experience includes over 6 years as an independent osteopath, working with multi-disciplinary fields alongside general practitioners, sports doctors, and physiotherapists to provide a higher level of effective recovery for his patients. He has engaged with high-level athletes in the field of tennis, soccer, rugby, field hockey, basketball, dance, ballet, trail-running, and triathletes.

To achieve long-lasting results, Taras strongly believes that structure and function have to be considered equally. His methodology includes an emphasis on educating patients about their pain, and to consider that effective recovery and treatment extends beyond the therapy room. Education is a key component to treatments when walking with patients for their road to recovery, with a mixture of in-clinic and home exercises (stretches and strength focused) as keys factors to improve symptoms.

A French national, he enjoys the fast-paced environment of Hong Kong, with his two kids and wife his loves alongside a keen interest in tennis and running.

Hamish Dickie
Senior Physiotherapist

Hamish originally undertook a Sports Science degree at Otago University and followed this up completing a physiotherapy degree at the Auckland University of Technology. A proud Kiwi, Hamish has worked with a number of high-performance teams and individuals and was part of the New Zealand Olympic team in 2018 where the team won 2 medals.

The first NZ Winter Olympics medals in 26 years. Hamish is still involved with the New Zealand Olympic program and physiotherapist for the Hong Kong Rugby men’s team. In 2018, Hamish’s wife Alex gave birth to the couple’s first child Charlie who has quickly become the apple of his father’s eye.

Prior to Hong Kong, Hamish and Alex spent a number of years in beautiful Queenstown, New Zealand where he developed the regions first high-performance youth sports academy to progress talented athletes. Hamish has worked in other high-performance programs including the New Zealand Baseball team and has worked at major tournaments such as the New Zealand Golf Open.

He has also worked in house at CrossFit boxes and is enjoying working with the CrossFit and weightlifting community in Hong Kong. Hamish was the physiotherapist for the Hong Kong Cricket Club rugby section in 2016/17 and is an active member of the cricket section where he captains the Optimists Sunday premier league team. An avid fitness enthusiast, Hamish loves all the running options that Hong Kong offers and is an avid runner on the wonderful trails.

Needless to say, Hamish understands sports and has a special interest in biomechanics and strength and conditioning components of rehabilitation. Hamish is also a qualified dry needling technician and uses a number of mobilizations, soft tissue and active release techniques to enhance the recovery process. Whether you’re a weekend warrior, youth athlete trying to reach the pinnacle of your sport or an international athlete Hamish is the right physio for you.

Charles Wang
Senior Physiotherapist

Charles completed his Physiotherapy degree at the University of Sydney, Australia. Charles has a particular interest in the link between biomechanics and injury, especially in the lumbopelvic area and lower limb. As such his treatment approach incorporates manual therapies and exercises prescription to optimise movement patterns and to recover from and prevent recurring injuries.

Joe Zhang
Physiotherapist

Joe graduated from the University of Sydney and has worked with a variety of athletes and programs, particularly at the Olympic and Professional level. He was a physiotherapist at the NSW Institute of Sport, working across all the programs in particular the Cycling, Hockey and Wheelchair Basketball programs.

Joe was also a team physiotherapist at the NSW Waratahs Super Rugby team and Sydney FC’s W-League team. He worked also as a state program physiotherapist in gymnastics and netball.

Joe’s treatment approach incorporates soft tissue release, dry needling, mobilisations and exercise prescription to speed up recovery, optimise movement patterns, and prevent injuries from recurring.

Joe has played representative basketball, and was also involved in weightlifting.

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