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.

Dereck Fu

Physiotherapist

 

Dereck completed his physiotherapy training at the Hong Kong Polytechnic University. After graduation, he started practicing in a public hospital where he had extensive experience in treating different musculoskeletal, orthopedics, and sports conditions. He recognizes the complex contribution to pain and musculoskeletal injuries and is keen on using a wide range of skill sets such as exercise therapy, manual therapy, and acupuncture tailored to individual conditions.

Before joining HKSC, Dereck completed his Master of Clinical Physiotherapy (Musculoskeletal Physiotherapy) and accreditation in Level 1 strength and conditioning coach under the Australian Strength and Conditioning Association (ASCA). These exposures enriched his practice, considering the psychosocial, biomechanical, and training load aspect of the clients’ story.

He has a particular interest in treating sports-related injuries and desk job conditions, assisting clients on their way back to function, and prevent recurring injuries.

Dereck has been a sports enthusiast since his teenage years. He is a keen football (soccer) and badminton player who treasures the enjoyment and satisfaction brought by both team and individual sports.

Icy Bo Lin

Head of Mobility

Icy has spent thousands of hours studying yoga, stretching and mobility through a broad range of in-depth courses. She has more than 7 years of experience teaching group and 1-on-1 classes to people ranging from athletes, pregnant ladies and new mums, children and especially the average Joe’s.

Icy is passionate about helping people move better, recover well and get pain free.

She believes it takes a combination of tools to help build a healthy body and has therefore spent substantial time practising strengthening and conditioning as well

Her passion for her craft is demonstrated through a focus and attention to detail with her clients.

Icy is a mother, experienced former banker and we are proud to have such an accomplished person on our team.

Below is a list of her completed training:

Leslie T. Evangelista

Head of Strength and Conditioning

Leslie’s athletic achievements speak for themselves. She is a true world class power lifter and continues to compete at the highest level. She has reached the pinnacle of her sport, medalling in a number of international powerlifting federation events. She has been Asia’s best lifter and holds a number of national records.

As impressive as it is, Leslie’s athletic resume pales in comparison to her passion, knowledge and dedication to the science of physical human performance. She is a student and expert of strength and conditioning, working in the industry as a coach and consultant for 10 years. We are very glad to have her on our team as her technical knowledge of compound movements and training methodology helps us bridge the gap between injury and a better you.

Leslie takes most pleasure in teaching the average person. Leslie’s deep knowledge and experience means she can build you from the bottom up or take you to a level beyond your expectations. Whether you are a mother or a mother to be, an office worker wanting to learn how to keep strong, or a youth wanting to learn the essentials of training, she is the expert for you.

Leslie is available as a consultant for long or short-term basis if you are serious about improving your health. She is an invaluable asset to have on anyone’s team.

Hideo “Harry” Loasby

Head Running Coach, Founder of BuffCo

Harry discovered running at 16, and quickly rose through the ranks in Hong Kong and became a national champion over 1500m when he was 17. He represented Hong Kong at the Asian Schools Championships and won several gold medals in cross country and track. Harry’s performances earned him a place on the Loyola Marymount University cross country and track team.

Towards the end of his university career, Harry became increasingly interested in studying various training methods and running philosophies. After moving back home, and knowing first hand the gap in grass roots development in Hong Kong, he set up Buffalo Running Company (BuffCo) in the hopes of changing that for the better. While coaching full time, Harry has remained competitive in the local scene, winning the 2020 China Coast Marathon by over 8 minutes. During the absence of races, he coached himself to personal bests in solo road time trials in the 10k and half marathon, running 31:38 and 70:30 respectively.

After running and now coaching in Hong Kong for the majority of his running career, Harry builds his coaching and training philosophy around the context of the city and what it means to be a runner here. He enjoys hunting for excellence in every level of runner, because he knows what Hong Kong’s running scene has to offer despite the tough conditions. From complete beginner to aspiring college athlete, on any surface over any distance, Harry is keen to help you with your running journey.

Harry is available as a consultant for any race you have on the calendar, but he is particularly passionate in developing runners over several years and building a sustainable relationship with all aspects of the sport, so that you can enjoy a lifetime of healthy, happy running.

May Lee
Sports Massage Therapist and Sports Scientist

May is an Internationally experienced Sports Massage Therapist, she focuses on deep tissue massaging to aid recovery, optimise performance but also general health and well-being. Throughout her years of training and watching others train, May has found that many people neglect the recovery process. The recovery process is fundamental for muscles to grow and develop and more importantly to reduce injury in the long term. Deep tissue massage helps to smooth out those little aches and pains you experience in normal day to day activities.

May has studied Sports Science at degree level and has completed her Level 4 Diploma in Sports Massage Therapy in the UK as well as being qualified in Dry Needling, Myofascial Release, Trigger point therapy and Pre-Hospital immediate care in sport.

She has previously worked a ski season in Niseko followed by working in clinical practice in Tokyo before deciding to move to Hong Kong to pursue her career further.

May has always had a keen interest in sports, training and exercise which has allowed her to pursue a successful career within sports and exercise rehabilitation.

Lizemari Marais
Physiotherapist and Pilates Instructor

Liz is a Physiotherapist and Pilates Instructor from South Africa. Her greatest passion is health education and empowerment, which is why she flourishes in the corporate wellness setting. She’s good at analysing corporate settings to determine risk factors to individual health as well as employee productivity. She will not just remind your employees to sit up straight – she will walk a path with your company to encourage healthy lifestyles and happy employees.

Liz’s approach to rehabilitation is grounded in the balance between mobility and foundation strength. She explores this in her calisthenics, yoga and pilates. She believes that with the right foundation and training, the human body can do anything.

Liz values independence and wishes to equip her patients with everything they would need to maximise their body’s potential, allowing them to pursue independent lives.

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