BACKGROUND AND HISTORY
Female, competitive level runner, 27 years at time of first assessment (DOB 1990).
Patient had right-sided heel pain in 2007. She had 2 injections and further treatment, the injury took 2 years to settle. In 2011, she had a stress fracture of the 4th metatarsal on the right side.
Patient came to Run3D as she was continuing to have right sided problems with her calf, hamstring (including neural symptoms) and ITB syndrome. She had returned to running but felt she was being held back by recurring problems.
3D GAIT ANALYSIS MAIN OBSERVATIONS
• Power Generation: There is a relatively low hip extension but increased knee and ankle dorsiflexion and as a result, a low vertical excursion.
• Control: There is a general asymmetry at the pelvis, hip and knee. Interestingly, right pelvic rotation is notably excessive at foot strike and whilst right hip rotation is restricted, adduction is excessive. At the knee, motion is greater on the left.
• Ankle: There is a slightly high inversion angle but average eversion and as a result, the eversion excursion is slightly high. The asymmetry in dorsiflexion at foot-strike (reduced on right, high on left) indicates a forefoot strike pattern on the right, with a mid/heel strike on the left.
• Strength: There is reduced hip extension strength and given the level at which she wishes to perform, hip adduction, external rotation and ankle inversion/eversion should be improved.
• Flexibility: The external hip position is confirmed and there is notable inflexibility of the quadriceps and hamstring muscle groups.
The right forefoot strike/absent heel contact was a surprise. On questioning, she feels she may well have trained herself to reduce heel contact on the right due to her plantar fasciitis. Certainly, it is quite possible given that she has an excessive step length (over-stride), she is having to rotate the right pelvis internally in order to get a forefoot strike. This is limiting hip rotation but precipitates excessive adduction.
In addition, she is not getting sufficient hip extension which may well be associated with the excessive step length and the weak hip extension. Instead, she is generating more through the knee/ankle but in turn has reduced hamstring and quadriceps flexibility.
1. Footwear: Based on the results of the analysis, a neutral shoe should be sufficient.
2. Orthoses: The asymmetry is not due to her underlying foot structure and is most probably due to her modified gait and proximal function. Whilst one could consider heel lifts, at this stage we should focus on rehab and running style.
3. Flexibility: The objective clinical evaluation indicates that the key areas to target are: Quadriceps and hamstrings.
4. Strength and Conditioning: The objective clinical evaluation indicates that the key areas to target are: Hip extension which should help improve power generation during running. However, given the level at which she wishes to perform optimising hip abduction (it is relatively weak on the right), hip external rotation strength, hamstrings and ankle inversion/eversion will all be of benefit.
5. Neuromotor Control: Optimising neuromotor control will be an important feature of the rehab programme.
6. Mobilisation: I performed a mobilisation today which did improve function and one would hope that improving strength, flexibility and the loading pattern would help prevent recurrence.
7. Running Style: The reduced vertical excursion is due to the degree of ankle and knee flexion during stance. We did discuss the excessive step length and this may be a feature that we need to address, particularly given the right forefoot strike/reduced heel contact and the pelvic rotation. However, trying to control the hip adduction may be more beneficial in the first instance.
There is obvious asymmetry and all of her symptoms are right-sided. On balance, she may well have adapted her gait such that she has a forefoot strike on the right side hence the degree of asymmetry. We have therefore agreed that we would take a balanced approach of rehab and gait retraining to try and address the problems. She is going to need to do the specific strengthening and flexibility exercises so that she has the underlying function.
In the first instance, she is going to perform some of her light runs with a view to contacting with a heel strike. I will liaise with Ken Hoye and she will return for an appropriate strengthening programme but also real-time gait analysis. The aim here would be to have her control the hip adduction in the first instance to assess the degree of benefit/affect elsewhere but also vary step length to see if this can reduce the asymmetry. The aim would be to review progress in 3 months.
REHABILITATION PROGRAMME PHASE 1
Rehab began with mobility around the hips, quads and hamstrings. The hip flexors and TFL were also targeted with stretches. Trigger point on the ball was used to reduce tension in the glutes and TFL also. Patient was advised to use foam rolling regularly and have sports massage therapy as required.
The MSK also showed reduced glute activation strength and so the glutes were targeted with step ups, lunges and work with a theraband. Her usual routine was reviewed and some positions were adjusted for maximum effectiveness under physiotherapy guidance. This included some core work including side plank.
A Hoka shoe was introduced for training runs as a Run3D trial showed improved foot function with greater symmetry and reduced dorsiflexion on foot-strike. There was also a reduced inversion at foot-strike. Patient has since returned to more traditional footwear and wears the Hoka more sparingly.
Balance work with a wobble cushion to add some instability was introduced later, the aim was to improve activation around the foot and ankle. Less work was done on this area as the athlete had returned to competition and was injury free.
Various cues for gait retraining were tested using Run3D in an attempt to improve the asymmetry at the ankle, hips and pelvis. A repeat assessment one-year later confirmed improvement at the pelvis and hips, although there is still a notable difference in foot-strike pattern between left and right.
REPEAT GAIT 12-MONTHS LATER
A repeat gait analysis was conducted 12-months later. The athlete was uninjured by this time, training an average of 60 miles/week and competing at a high level in all distances up to the marathon.
• Power Generation: Improved hip extension at toe-off, pelvic tilt position and hip flexion at foot-strike, resulting in reduced over-stride. Improvement in knee flexion.
• Control: There is notable improvement in the asymmetry that was previously observed at the pelvis, hip and knee. Right pelvis rotation at foot-strike and hip adduction have decreased, there is increased motion on the left.
• Ankle: There is relatively little change at the ankle, with some improvement in ankle inversion at foot-strike on the right, probably a result of the reduced pelvic rotation at foot-strike that is observed. Given that the athlete is running well and uninjured, the asymmetry at foot-strike will continue to be monitored but not directly altered at this time.
Training has gone well and the athlete managed to build up to a week of 87 miles at the peak of her marathon training, resulting in a PB by 10 minutes and an England call-up. She also ran PB times over a variety of shorter distances including 10k and half marathon.
She has regular soft tissue work and maintains some strength work throughout training. Since her marathon she is keen to add more power and strength to help prevent further issues and to help improve speed. She is also looking to add more speed work and race over shorter distances before building up to another marathon.
The current phase includes some free weights building on some classic lifts such as squats and dead lifts before moving onto more power based moves. Single leg work is still an area of focus to further improve symmetry. As there is more of a speed focus for the upcoming training block, plyometric running drills will be included in her programme to help convert the strength to power.