What The Cup !? A Podcast
Here you'll find podcast episodes and other resources all about human resiliency, endurance sports, strength and exercise training, Myofascial Decompression, the latest fascial science, and other MSK concepts from your friends at Cup Therapy. Listen to interviews with Dr. Christopher DaPrato and some of the best athletes, clinicians, and researchers in their fields. Thanks for rating and subscribing!
What The Cup !? A Podcast
Episode 31: Running Safe; The Myths and the Science of Running Injuries
Welcome back! We are excited to debate new evidence based discussions this year for our great audience. This episode dives into the current literature on running mechanics and the nuances of treating the running athlete. We cover some of the many in depth tools and applications that are covered in our new online course "Clinical Running Health; Applied Biomechanics." The new 6.5 hour CEU course can be found at IntegratedMovementHealth.com
We are back in 2024 and we are doing a podcast with a really important guest to talk all about running, running research, running injuries, and how to run safe. Rich Sousa, how are you doing?
Rich:I'm doing well. How are you, Depredo?
Chris:Dr. Rich Sousa and myself have put together, along with Anthony Luke, an online, fully immersed, level 1 running assessment course, which is going to systematically take you through the running analysis, what the research says, what the literature really discerns on different populations. We'd love to talk to you guys about that today. So I want to ask Rich right away, what got you into the running community to try to assist these injuries and look into it with a
Rich:research lens? Yeah. As a physical therapist, I was in the clinic treating runners, and really had more questions than answers. And that was frustrating to not know what to do with these runners that have these kind of chronic running injuries. When I went to do my PhD, the population I worked on were females with patellofemoral pain, a condition super, super common in runners, as you know. And my dissertation work looked at hip kinematics and women with patellofemoral pain. And we found some really important findings that at that point were new. Now, I think that everybody kind of understands the connection between the hip and patellofemoral pain, but, um, that was a time when it wasn't as, as obvious. And as I've, gone through my career, I've always been interested in running.
Arpita:Hey there. This is Arpita. I'm a science communicator and physical therapist helping you break down some of the terminology that Chris and rich use in this episode. So rich mentioned patellofemoral pain, which is an umbrella term used for pain in the patellofemoral joint. And this is where the kneecap meets the thighbone. It's a chronic condition that tends to worsen with activities like squatting sitting, climbing stairs. And especially in this case, running. It's usually a combination of several different things, including overuse and overload of the patella femoral joint, muscular weakness, imbalance, or dysfunction.
Rich:Um, I still do some running research. The bulk of what I do is actually, kinematics and kinetics of people with osteoarthritis and in activities of daily living, like walking and rising from a chair My clinical interest is still firmly Grounded in running. As you know, we have a run safe clinic, which is a multidisciplinary clinic that was developed by Anthony Luke, our partner in this, course that we give, to bring different clinicians together to help runners. Um, and it's been going for just about 20 years, I think 2005, 2004 was right when they started it. And I've been involved since 2008. I get enthused about the running, running mechanics and running research every single time I go there. I want to learn more. And so that's kind of where it started. Some discussions that you and I have had over the years with, uh, other clinicians in the community has now transformed into an elective for our physical therapy students that, I give every year. And in that. In that elective course, we dive into the research. So it allows me to stay up on the kind of most current research regarding running biomechanics mostly, but, but running, research in general.
Chris:I really appreciate you keeping all of us. You know, up to date, I would say, because it's challenging, I think, to stay on top of the literature these days. There's so many journals, so many new journals, with so much different types of research out there. And we've really, I think, seen the landscape of the research in the running community and running injuries change a lot. Can you define maybe just a couple of those areas that have really, evolved in the last 5, 10, 15 years that you've been a part of this?
Rich:Yeah, now you bring up some, some good points. It's hard for anyone to stay on top of the emerging, information that's coming out. There are a lot of journals, there are a lot of labs, a lot of really good labs. It used to be in the eighties, you just waited for Peter Kavanaugh to publish another paper and whatever he said was the latest on running. Now, there's lots of labs that are doing really good work. So, staying up on it, can be, can be really, really challenging.
Chris:Yeah, even I feel like I'm surrounded by academia. I still get confused
Rich:constantly with this. Many of the results differ. Um, some of the study designs are slightly different, which can totally change results. Sometimes the study designs are exactly the same and the results are different. But the, the one thing that, I think is really important for all of us to remember is that over the last 20, 25 years, research has taught us a whole lot. Injuries haven't changed. The rates are pretty similar to what they were. So we have not figured this out despite all of us. Figuring it out, right? We think we figured it out, and yet we are making incremental changes. I'm not sure what massive pendulum needs to swing for us to actually start getting a better grip on this, but this is a problem that we all need to understand is not, it's not solved. We have more work to do. Yeah, and I really
Chris:love the idea that this is a moving target. And we figured out so much, I think in the last 10 years, I started run safe with you back in like 2011. And I feel like I've grown exponentially in my understanding of the literature. And yet, like you're saying, the rates of injury are actually increasing, not decreasing. Even though we have this, you know, great data coming out and better idea of what is causative, what is correlative. And yet we are still missing some of the mark. So I think one of the things that I've seen kind of come under the gun from the research enthusiasts and people that are really trying to simplify clinical practice is that do the biomechanics even matter anymore? Because we see arguments that, well, pronation, which we used to think was evil, is not so evil as we thought. And the idea of. Having a large Q angle, what does that look like from a static versus dynamic standpoint? And even some of those things don't seem to matter for the running injury sustained.
Arpita:Chris mentions a lot of terms here, so let's go through them. Pronation for this purpose, we can think of as flat feet, quote, unquote, imagine that the arches in your feet are flat and that most of the sole of your foot is touching the ground. This is pronation. Pronation is also related to Q angle, which is the angle between your thighbone and a straight vertical line down the middle of your body. If you stand in front of a mirror, you'll see that if you bring your knees together, kind of knock-kneed, your thighbone is angled more inward and therefore has a higher Q angle.
Chris:So how, how have you seen the shift in terms of how prioritized biomechanics are in predicting running injuries in your scope of practice?
Rich:Yeah, it's it's a fair question, and to get super like philosophical and out there on you like biomechanics are everything and biomechanics are nothing, right? And you could say that about all aspects of running, you know, programming is everything and nothing shoes are nothing and everything. And that's because you can't take. One aspect of running medicine and look at it in isolation and expect it to really explain much of anything. You could give me very clear biomechanics down to the exact stride. You know, mechanics, the kinematics and kinetics, the motion, the timing, the temporal spatial and in two or three different runners, you could conclude that these mechanics are safe in somebody and they're injurious in someone else because you have to bring the whole picture together and part of that is daunting, right? Like, so part of that is like, well, then how are we ever going to figure it out? The great thing about it for clinicians, for people who are really interested in running medicine. Yeah. Is that's that's why we are so important because we have to put it all together on a single runner basis and understand how this person comes in. What are their tissue mechanics? What are their susceptibilities to injuries? Maybe, you know, my Achilles Since I've, uh, ruptured it about five years ago, it's not the same as it was before, right? You need to take that into your picture of running mechanics and say, all right, well, maybe Rich shouldn't be a forefoot striker since he's got this tissue, which is not fully remodeled.
Arpita:Richard mentioned that he tore his Achilles tendon in the past. This thick gropey tendon on the back of the heel is part of your calf muscle, which is responsible for pointing your toe. If you're a runner who lands on their toes, this will ask a lot of your calf muscles. So for someone like rich, who maybe doesn't have the strongest Achilles after an injury landing on his toes is maybe not the most sustainable running form.
Rich:Now, somebody else, young person like yourself might be able to run with those mechanics. And everything else can remain the same. And for you, it's safe. And for me, it's not. And so, um, biomechanics, yes, they do matter. And, and I'm a huge believer that, that biomechanics are modifiable and a tool that we really need to embrace because that is our mechanism to improve injuries and running experience for folks. But you can't just look at biomechanics by itself, or it's just a losing game. Yeah,
Chris:like you said, it's the variability within the biomechanics, right? And I think you touched on what I think hopefully is what most people come away with is it does matter in some situations for the individual that's in front of you. And if you can apply the science and what the research says. and trickle it down into the person and the human being that's there in front of you and take all those variables into account. I think that does play a huge role with it where we have to use the literature to our advantage as often as possible,
Rich:right? Yeah, I can give you an example that kind of illustrates I think what you're talking about. And that is, the idea of stretching for injury prevention, right? So when I was young, probably when you were young, stretching was part of what we did. You prevent injuries, you have to warm up, you have to stretch or else you're going to get injured. And then literature came out that really showed quite convincingly that, this passive kind of long hold stretching doesn't change injury mechanics. And I believe that literature, I think that it probably, doesn't on a population basis, reduce injuries. However, if the runner in front of you has a focal lack of extensibility in a key muscle or joint, And it's changing the way that they're running, then absolutely in that person addressing flexibility and stretching and trying to get more motion, whether it's actually the muscle that's lengthening out or capsule or whatever it is, it's critically important for that person, but on a population basis. No. And so, literature is often looking at large groups And it's not the entire population. It's a sample of that population, sometimes 20 or 30 or 40 people. And we're expecting it to describe the whole population. But when the runner is in front of you, you're not even looking at the sample. You're looking at N of one, and you're trying to make conclusions about what are the right biomechanics, what are the right, you know, exercise programs for this one runner. And in that regard, you know, some of those literature, the data from the literature can. If anything, to a point you in the wrong direction.
Chris:I love that example. And let's just continue with that. Let's say you have someone, this N of 1 that's in front of you, and they have really tight hip flexors. On a Thomas test, they're off the charts, restricted. And they're trying to train for that first half marathon. And at mile 8, their back starts to hurt all the time. They start getting loading issues, and their back is really locking up, and they have a lot of soreness. In the lumbar spine, I think that's a perfect, you know, example of maybe this person is someone that stretching could do a huge amount of service for to reduce the amount of tension on that side of the spine, because again, stretching doesn't play out very well when you look at the literature in a large group of, you know, N equals a thousand, but how many of those N equals a thousand have a positive Thomas test for hip flexor tension?
Arpita:The Thomas test is something a PT might use to check the flexibility of your hip flexors. And this test, you lay on an exam table with your low back flat on the table. One leg hugging your chest and the other hanging off the table. If your hip flexors are tight, your thigh and the testing leg will be higher than parallel to the table. Chris also mentioned back pain. Some of the muscles that we use to flex our hips, connect to the lower part of our spines. So if these muscles are tight, they might cause back pain, especially while running.
Rich:Absolutely. Yeah. Perfect example. So that's, that's exactly a situation where that runner, it does not look like the entire sample. And so using the literature, listen, I'm a researcher by occupation. So I, I very much value the evidence from the literature, but we have to understand its limitations. And so we look to the literature to get ideas of what are the variables that are interest on the population basis, but we also have to trust your clinical tuition and what you see in front of you. Yeah. And let's play
Chris:devil's advocate. Cause here's what some of the people that say, well, you know what, biomechanics just don't matter. Let's program it and slowly ramp you up from mile one to mile six where you don't have any back pain. And let's go slower from mile six to mile eight when you do get the back pain. And let's take our time and go over the next three months to go from mile six to mile ten for three months ramping as slowly and very intentionally as possible. And then do we actually need to pay attention to your tight hip flexor and your lumbar lordosis or some of the positional aspects of your running biomechanics? That's, the, the argument out there, I think,
Rich:You know this about me, but I am definitely never going to be somebody who thinks that there's one way to solve the problem and programming is critical. And I think the literature has shown that there are ways to do this safely and ways that people can progress. That being said. To completely ignore biomechanics by just progressing somebody in a evidence based manner, and not addressing things like, you know, joint mechanics, how heavy they are, whether they're overstriding, whether or not they have poor hip, knee and ankle alignment, the frontal plane projection angle, not addressing any of those things and allowing them to continue as you are increasing the tissue tolerance, right? So you're basically bringing them up, but not improving it to me is, is, just as. Bad of an idea as only focusing on biomechanics and not thinking about the programming that they're having or the distance that they're running or the speed in which they're running it. And we've done this in, in our profession, in running medicine for decades is we've planted our flag in one area or the other. Oh, Let's just all take off our shoes and be barefoot runners. And then all of a sudden, everything wins. Let's use a hocus. Let's do chi running. And I've always been a believer that like, let's not just do one thing. Let's do all the things it makes for a super complex algorithm. And I get it for people who want to have a solution. It's challenging to integrate that certainly challenging to integrate that into any type of a research program that can prove that it works or not because it's just exponentially harder to do the more variables that you're controlling to even find a sample that fits what you're what you're trying to explore. Um, but I have to tell you if you're asking like my belief, I believe that it's not just programming. It's also not just biomechanics. Yeah.
Chris:Let's continue with that same idea of someone coming in with tight inflections, they get pain at mile eight with their lumbar spine and we help them with the biomechanics and they now want to go from a half marathon to a marathon. And then a year and a half later, they just love marathons. They've done them three or four times. They want to do an ultra. I think this is really where the bomb attacks pay off dividends, when we think about like lifting technique and you're going to do a snatch or you're going to do a back squat or you're going to do a deadlift, clean lines, straight lines are strong lines, right? Like you can lift with poor form with a back squat with a lightweight and not get injured. Research has shown that, but can you lift with the deadlift with high intensity? And looking at that population over time, do they get a higher incidence of injury? We just don't have the data yet, but it makes common sense when we think about why biomechanics matter so much.
Rich:For sure. As you talk about that runner that wants to push and go longer and longer distance. Um, 1 of the challenges that I face, is. Finding a viable solution for our runners who come in that want to run really long distances and run really fast because those two things are somewhat at odds with each other. I feel pretty confident after doing this for, you know, 15 plus years that I can. Give somebody guidance to make their running softer and make it probably less injurious. But often that it results in kind of a reduced running velocity. Certainly not increasing running velocity to make them softer, gentler, easier. It doesn't mean, you know, walking, we can get people at, you know, nine to 10 minute miles with very, very soft mechanics. But if you tell me you want to run six. minute miles, and you also want to run a 50 miler. I find that case challenging. I'm sure there are, you know, running coaches, out there that probably have the right solution to that, but, we don't see that many people at RunSafe that want to do that. We see much more the runner who is, um, really wanting to stay healthy regardless of their speed. That becomes the more challenging runner to me. I'm not sure what your
Chris:thoughts are on that. Yeah, I agree. And again, they are at odds with each other. I think that's when the programming comes in where we talk about what the timeframe is that they need to responsibly plan for to increase the intensity or increase the efficiency, and I think that's one of the things that our course does try to pick apart. Like you want to train both. Most people don't want to just. Not get injured and just stay at a 10 and a half or 11 minute mile their whole life. Like, everybody at some point when they get into the running, you know, activity, they want to go faster. We are all, most of the time, competitive, at least within ourselves, to try to improve it. And, you know, some of that is, I think, driving force for why we want to do it more. It's exciting. And I think it, it's a really great tool to use, but like you said, it's a double-edged sword.'cause the faster you go, the more likely you're going to put more stress, especially on tendons and in tendon health that's coming out with, with lots of literature there on what speed does to that tendon is really important. And, and when we jump into that a little bit in the course as well, but talk about, talk about what your experience in the last 10 years has been with tendons and tendonitis and tendinopathy and, and some of that, uh, literature that you've
Rich:seen. Yeah. So, you know, the, the literature has gone over lots of changes in the last 10 to 15 years, just from understanding what aspects are truly inflammatory and which are not, um, you know, the, one of the things that I've learned, which is critical. I don't think we've talked about it yet. And I wanted to, to bring up is, age. Plays a role, so we often see younger high schooler, college aged runners and they'll have a tendon flare up. They'll have some sort of a tendonitis or maybe a tendinopathy, but they heal quickly, right? You contrast that with a runner in their fifties, sixties or seventies and all of a sudden that tissue repair is, is quite different. And so, uh, you know, understanding the inflammatory process of a tendonitis, or the lack thereof in a, in a tendinosis is critical and in, in bringing in the age, aspect of it is also something that I've learned we can't ignore as well. Yeah, definitely.
Chris:It comes back to what is their previous experience with running, what's their previous experience with exercise and resistance training. And that really plays a huge part of how you're going to change their programming to try to remediate their itis or their apathy to try to get them back to the thing that they want to do. Runners don't like doing weights most of the time. We have to give them really solid, creative ways of introducing resistance and load. To improve the low capacity, especially as they go through that aging spectrum. So we have to really
Rich:come to grips with
Chris:the tissues of the body start to change at some point. And these days people are trying to push their limits longer, harder. Longevity is such a big buzzword these days. And people want to be running into their 80s, 90s, and maybe hundreds. Maybe 110s 50 years from now. So, you know, part of it is like applying this literature is really helpful in applying the biomechanics, but I think thinking about the long game and not just the short game. And I think that's where the biomechanics for me really play in the biggest part. Like I said, you can lift, you know, a couple of weeks of a moderate load and half crappy form, and you're probably going to be okay. Or run that, you know, extra mile or two, and you're probably going to be okay. But what does that look like a year later? What does that look like 10 years later? That's I think where the biomechanics really shine it. And I think that's where the value really comes out the most in the course that we've
Rich:put together with this. Yeah, you know, sometimes it's it can be a little bit frustrating when you look at the literature and, you want it to validate what we think we see in the clinic all of the time. And often it doesn't go to that level. Right? You look at somebody that has, poor frontal plane alignment. So this is the frontal plane projection angle or the medial collapse that is often described as, a kind of pseudo dynamic valgus.
Arpita:Medial collapse and dynamic valgus is similar to what we mentioned earlier with the Q angle. Imagine the same knock-kneed position happening, but this time, while running, instead of standing. It's also usually associated with a hip drop and pronation.
Rich:Um, and the literature is surprisingly mixed there. You look at it and you say, there's no way this can be healthy for this joint, right? And there is certainly some evidence, don't get me wrong. I'm not at all saying that, um, a dynamic valgus is not an important variable, but I think we thought that biomechanics was everything. I think we thought 15 years ago that if we could just fix that, if we can just identify and fix it, that was it, but it's not, it's a very complex problem. And it, it doesn't tell the whole story. Um, how you. Use your muscular strength while you run is critically important and underappreciated.
Chris:Yeah. I definitely agree there. Runners love what, whatever the latest hottest thing runner's world comes out with. I think this reductionist viewpoint of the body of like, Oh, all it was, was getting out of these. Thick shoes that Nike started producing in 1970s. And that's why injury rates went up. And all we needed to do was go to barefoot running. And if you do that, it's going to be fine. And then, you know, we had class action lawsuits and, you know, the vibrant five fingers kind of really lost a lot of speed and then, you know, the cushion movement and I love my Hoka's, you know, I love my Hoka's, but again, it's not something that's going to fix. You need to tie in the variables together. And I think there's been so much of this reductionist, argument and discussion within our professions that really we don't appreciate how this one variable is magnified with all the other things surrounding it. And it is one of those things. I think, you know, we, we go in depth into this. Will Walker 2022 systematic review where they really took a really big undertaking of trying to look at all these big injuries and what are the causative factors or correlative factors when it comes to the biomechanics themselves. And so when you look at that, it's a huge mass of information and data trying to, you know, systematically review all the things that are appropriate for the type of runners that we're looking at for IT band syndrome. Or all the things that we're looking at for someone that suffers from medial tibial stress syndrome. And we see that some of the literature there is very thin, and has high risk of bias. And then some of the literature points, Okay, this is all going the same way, and seems to point that, Well, yeah, if you have a large eversion angle for a long enough time, You probably have a higher likelihood of developing medial tibial stress syndrome. So, I, I think for, for our listeners here, like, where do we Start and how does this course that we've put together give us a good handle on how to discern some of these variables?
Rich:Yeah. Great article, by the way, it's something that we look at in the course. And I think it's it gives us a lot of discussion points, because it does show you the contrasting literature. Well, you'll notice in that article is that, for certain diagnoses or conditions when there's 1 or 2 studies, they happen to agree. We feel pretty good. We're like, yeah, we kind of know what the risk factors are for that condition, but the conditions that have. Ample research, uh, patellofemoral pain and IT ban. All of a sudden there's conflicting research, right? When one study finds one thing and one finds another. And, I'll tell you a story, about subgroups and differing research. So, um, I, I had mentioned earlier that when I was doing my dissertation work, I was looking at females with patellofemoral pain. That were runners. And we evaluated their kinematics and kinetics, a group with pain and a group without pain age match that we're controlling at all. Everything was great. I think we had about 30 subjects in each group. Man, I think that's right anyways. And we looked at running, we looked at step down and we looked at a drop jump task. Well, just so at the same exact time, John Wilson over in Irene Davis's lab at the university of Delaware was doing almost the identical study. And almost the identical population. His tasks were a little bit different, but we're both in females. We're both looking at hip kinematics. When our results came out within like three months of each other, this is, um, 98, I believe 1998, maybe 1999. Um, he, uh, sorry, that is, those years are wrong. You're
Chris:aging yourself here. And no, not
Rich:2008, 2000. Uh, he, his results. Were complete in conflict of mind and we were very unclear about it. Um, and we just set up a call and we discussed it once and it turned out. that our groups. So let me tell you what the results were. Basically what my studies found is that females ran with much more hip internal rotation than controls. And we concluded, as you might suspect, that the internal rotation was the cause of the patellofemoral pain. It's jamming the patella against the lateral facet. Like there's this whole biomechanical model that explains why that could be bad. We didn't find any differences in hip adduction. And then John Wilson's work showed that all the differences were in hip adduction, that women with patellofemoral pain had greater adduction across tasks, and there was no differences in external rotation. In fact, I think his, uh, patellofemoral pain group was a little bit more externally rotated. So. Same study, same population. He also had somewhere around 20 to 30 subjects per group. So small groups, but we're finding different results. When we, when we finally go to look at our data and we were looking at the, the abduction, both John and Brian were, were very confused why my, in my sample, these women did not show increased adduction. I was surprised too. That was, I hypothesized that they would show increased abduction. When you looked at it, our patella femoral pain groups. Um, my control group and my control group were identical. My control group was different than their control group. So it ends up that you not only do you have to find the right sample of a study, you also have to find a great sample within the control population that doesn't have a predisposition to this injury as well. So that's just a perfect example where like we are looking at very, very small numbers, small groups of the population and small control groups. And so sometimes the differences that you're, you're going to see. are not by chance. I think there's something meaningful there, but man, it can be really, really fickle when you have small numbers like that. Um, our, um, community has a real, real problem with, creating adequately powered studies. We really need to ramp up and It, it, these, these running research is relatively poorly funded. It's hard for me to, you know, expect somebody to do a, a 2000 sample study, but it's what's needed to start to pull out some of these subgroups.'cause these subgroups do exist. I believe quite strongly that women runners with patellofemoral pain. A subgroup exists. Where inter rotation is the primary mechanism of the ideology of the disease. And I happen to have gotten several of them in that study. And so they ended up skewing the average so that it was significant there. And it just so happened that I had people that exhibited a deduction in my control cohort, which actually negated the fact that my, that my patella femoral pain cohort was also showing those mechanics, but not greater than what my control population was. So these subgroups are really what make. Diving into the literature and, and, and translating it to the clinic, really challenging.
Chris:Yeah. And the way I always like to think about it and frame the literature is like just because it's not statistically significant doesn't mean it's not significant for the person that you're working with right then and there. Right? I couldn't agree more. Yeah, that's, that's a big thing that we have to remember is that statistical significance for one variable. Remember, research, we're trying to isolate one variable out of all the variables possible. That's the best methodology. When you can. Eliminate all of the variables as differences between a control and a experimental group and that one variable is going to be the one thing that you're going to see the differences in their data. And that's kind of almost impossible. I think, you know, when it comes to something as complex as running, right? Because there's strength, there's biomechanics, there's You're running health. There's cardiovascular. There's so many things that go into this equation. So it makes it very challenging with that.
Rich:Yeah. When you're doing empirical studies, when you're, you're studying a phenomenon, uh, my, my daughter is in physics right now. She's Learning about Newton and gravitational pull. Like if you're studying gravity, you're gonna be able to, um, observe certain things and, and, and there's going to be some noise in the system, but ultimately, you're going to be able to see the phenomenon you're looking for. You shift to human subjects research and all the complexities that change behavior. And the noise sometimes can outweigh the signal. And it's just really hard to see, you know, the signal through all of the variability within the population.
Chris:I think it just validates the nuance. You have to take your clinical skills and apply them with good clinical reasoning and work through the algorithm that you are best equipped with. And the best way you can equip yourself with the, the best lenses to change and shift is to gobble up as much research as possible and get as many runners into your clinical experience as possible. I think that's the way you get better. And there's no, there's gonna be some groin pains for you as you go through this. If you just got out of school and you want to really treat this running population, there'll be some groin pains. Even if you were immersed in the literature for the last, you know, three years working hard at it, now you're going to get exposed to the human being that is going to have that running injury. And, and some of the aspects that we look at with, with that, I think, synthesis. Is where the nuance comes in and I think our course does do a pretty
Rich:good job of, you know, giving the learner
Chris:the research aspects and the pure biomechanics from Rich's modules that he goes through. And then I take it into this idea of clinical application and some of the, you know, down and dirty, like, what are the tools you need to use and apply in a very succinct way so that you can be efficient with that 30 minute visit with the person and do a running analysis within five minutes. and give them some, you know, advantageous things to work on in their biomechanics on that treadmill and maybe one or two exercises to go home and work on because strength doesn't mean good running mechanics and having poor running mechanics doesn't always mean they're weak so I, I do want to emphasize with our listeners that strengthening is always a good thing, but strengthening a muscle that's weak doesn't necessarily fix that. You know, if you have a weak glute, me doesn't necessarily mean you get it strong over the course of six or eight weeks that it's going to fix their contralateral hip drop. It just doesn't work like that sometimes, right? And we know, you know, working in our RUNSAFE program, correlating what we see on the treadmill and what we see in the PT physical exam doesn't always work out. And what do you take home with that, that type of, uh,
Rich:Yeah, thanks. Thanks for that. Yeah. You know, uh, for many years, 20 years plus, we had identified that, you know, perhaps hips weakness in general poor mechanics and, the obvious. answer was hip strengthening. And so, you know, for many years, runners would come in with these mechanics that were, poor. They would show evidence on physical exam of weakness of key muscles, usually at the hip gluteus medius glutes maximus. And we'd give them a whole host of exercise, a progression plan Had ourselves on the back and say, Yep, fixed another. Um, and then through our observations and some really important literature, rich Willie did this really great study where he looked at essentially exactly what we're talking. I looked at people that had poor running mechanics and then did an exercise strengthening program that was functional. In standing single leg squat included a progression, uh, increasing the demand on the abductors and external rotators and sure enough showed that they got stronger. And then when he looked at them back on the treadmill after it, mechanics were just as they were before unchanged, not improved after this huge strengthening program. What he did show is their squat mechanics improved. And that was just a huge, just game changer for me to understand the importance of specificity. Your strength on the table does not predict your strength in a squat and your strength in a squat does not predict your strength performance use of that muscle while running. And so this is where I've learned a ton from you and the other clinicians that I work with, you know, functional strengthening, it has to progress all the way to functional strengthening or you're not done. Um, I, I think that probably there's a subgroup of people, maybe 20 or 30 percent of people that if you do just. Give them the strength, the mechanics probably improve, uh, but a huge portion of them need functional strengthening, actually, um, strengthening on the, uh, on the treadmill.
Arpita:The official definition of functional strength training is training that attempts to mimic the specific physiological demands of real life activities. Think of it this way, instead of doing a standard deadlift with the barbell you'd instead do single leg deadlifts, maybe also moving into a lunge to better imitate the types of motions involved with running.
Rich:Why don't you share with the, with the listeners, the functional strengthening kind of protocols
Chris:you've developed? Yeah. I mean, and I just want to touch back on like specificity of subgroups. Like you're going to have 25 percent of the people that come in to see you that have dysfunction with their running. Purely because they're just damn deconditioned and really weak. They just needed that strength and as soon as they build up that strength, the problems do go away. And then you're gonna have the other side of that, you know, bell curve where you have a really strong, amazing physical exam with someone. They have no real You know, impairments in range of motion and strength. You just can't test it and pick up any of that yet. They have this huge contralateral hip drop. They have this huge amount of like maybe rotation or arm swing or, you know, valgus collapse, like they have these issues. And you're going to have to spend a lot more creative time developing standing drills with load going from the back foot to the front foot, and so thinking about more common lunge patterns, more common step up, step down things, depending on whether you're trying to target glutes or you're trying to target quadriceps eccentric. You know, control or plantar flexors. And I think my biggest shift in the last five years for my running population is really appreciating how important the plantar flexors are. And that plantar flexor group soleus gas drop and posterior tibialis. Like those top three things are just like. They're icing on the cake for me five, 10 years ago, and now they are like top of the list and I think, you know, really identifying what some of the running literature says on these muscles that are really important and maybe why some of the up the chain or down the chain kinematics or kinetic chain dysfunctions happen. And so I do really like diving into why these certain muscles matter and why we should focus more on some muscles than others. And then taking that and applying it into more creative exercise prescription, like you're saying, making it functional, making it as close to running as possible, right? So don't just grab a barbell and put, you know, 45 pounds on each side and start doing back squats. That's probably not going to be the fix. It's probably going to be something that looks a lot more like running. A runner is not necessarily going to buy into the barbell medicine that's really popularized out there or the CrossFit gyms. They want something that feels like running. And so I think we touch on how to do that in our, online course. And then we also have a level two course that we go into the physical exam and way more in depth into specific exercises that you can program in to make it creative and make it fun for the runners to get excited about intensity building and resistance training and those types of
Rich:things. Yeah, one of the things that I think is really powerful is showing a runner how quickly mechanics can change with education and queuing. I think most people think without having any background, uh, that, you run the way that you run and changing it is quite hard, but we can show that. Very quickly. You can change somebody's mechanics with the right level of queuing. And there's been a lot of studies that have come out with super high tech ways of providing feedback to runners to change their mechanics. And there have been some that are super low tech. There's a series of studies that have done mirror training where you're just running on a treadmill with a mirror in front of you. And you're trying to keep your alignment, whether it's your pelvis or whether it's your knee alignment straight, and it's been shown really, really effective. Um, and, and that's a strategy that, you know, I often are recommending to, runners and to our physical therapists that, um, that are using the evaluation that we teach in the course, um, to improve those mechanics. Start with the strengthening, the strengthening is important. Um, but then, you know, you have to go all the way to the point of functional strengthening, which is on the treadmill and using those muscles. Uh, during that task. Yeah. And, you know,
Chris:I think we do touch on even things as nuanced as shoes and running styles, right? There's things out there that are, you know, maybe for someone that's got pretty good mechanics, they've got pretty good strength and they just want to get a little better. Those things will matter for
Rich:the efficiency and, you
Chris:know, their ability to achieve the speed or the, you know, performance that they're looking for. And we do touch on that as well. But I do think, you know, if we've. said nothing outside of the idea that this is a very complex problem. You need biomechanics, you need strength, you need biopsychosocial skills to listen to them and hear what they've done in the past and what they're complaining about now so that you can make sure that they feel heard. Like, we want to take the human that's there. And I do think, you know, Acquiring a synthesis of this literature is really important and that's what this course really what we tried to achieve is getting the best literature out at this time and place and date to the learner so that they can kind of have that tool belt that they can apply these concepts with.
Rich:Yeah, the literature is super dynamic and that's it makes it challenging, right? And that's why, you know, having, um, a system by which you're, you know, aggregating the, the literature and bringing it together is really critical going to courses. And there's constantly, Con Ed where, where you can learn more about, literature running biomechanics, but it's also appreciating that things have changed, right? I mean, it used to be that you would match somebody's foot shape to their shoe and that was consistent with best practices at that point. And then the military studies came back and said, well, that's not changing injuries at all. And so we started thinking, you know, questioning some of those things. And that was all in kind of 20 to 22 year old, you know, mostly males, but some females in those studies as well. Um, and, and things have quickly evolved. There was a time when motion control shoes seemed to really Okay. Be quite injurious to just about anybody who put them on because that was the literature that we had. And that pendulum has shifted and have found some real, you know, populations to which motion control shoes seem to work. Um, again, my biggest gripe with many of those studies from, from shoes is. They are focusing on one single phase and I get it. I'm not I'm not I'm not saying that I have the solution to this. Um, but if you if you just change shoes and you're not looking at biomechanics and many of the other variables, running speed and periodization and all these things, it's it's hard. To come up with a accurate conclusion. Um, and so I, I happen to believe that, you know, most people, maybe not everybody, but most people can find safe running mechanics wearing just about any shoe that they choose. Um, if you do have that runner who just has injury after injury, chronic injuries, they've made some adaptations. We're working on, on, on trying to improve their biomechanics and we're just looking for more. Sources of shock absorption. We're just trying to soften things up and they're committed to their, Minimalist shoe or to something that has no cushion to them at all. I will lean more towards, you know, getting a shoe that has more cushion, but not allowing them to change their mechanics. You know, uh, Christine Pollard did a series of studies that looked at at the Hoka at the maximalist shoe and showed that your mechanics actually worsen. And it's, it's just in our own nature, right? You feel this. Big soft cushion on the end of your foot and you know you've got that shock there. And so your own internal mechanics stiffen to kind of match that softness. And so, um, I think that the best case scenario in that person is to, train them with soft. Biomechanics and then also take advantage of, um, of a shoe or, you know, whatever other sources of shock absorption,
Chris:you can find so many variables to play with. So little time, but again, that's that's one of the beauties of a complex course like this. We're going to give you all those different variables. I think synthesizing the literature with it and, you know, reconciling literature with it. Best practice and the things that we know at this date, again, running literature is very novel. It's not well funded. You have smaller sample sizes, but we can, when we put together multiple studies and look at systematic reviews, you can really get a better picture. I think for you to inform the runners that you're working with and talk about the shoes, the strength, the biomechanics. And some of the programming that you're going to work with them on. So, I think we did a pretty good job at it. Yet, there's so much more to learn. I really, I think that's what drives me, is there's so many more questions than answers. And I think as time goes on, I just, I look forward to updating the course and continuing to improve, like, what our variable
Rich:manipulation looks like. Yeah, the our valuation has changed drastically over the years, right? I mean, it, started with, um, just looking quite different than it does right now. And it changes every, you know, every year. The core of it probably is has been pretty consistent for a number of years. And that's because the analysis that we do is completely evidence based. It doesn't mean that all the evidence agrees with, uh, each other. Um, but. The evidence that is indicative of being related to an injury, there'll be multiple aspects of the systematic evaluation that point towards that variable and ones where there's kind of more loose and not as strong literature. There might be one evaluation piece within the analysis that that evaluates them.
Chris:I feel like we really dove into this running literature, into this, you know, world of runners, and we still have more questions than answers, so, you know, hopefully that, that's indicative of, you know, the complexity of this type of population.
Rich:It's an exciting place to be. I don't think it's it can be, um, overwhelming when you're first kind of exploring it. But the deeper that you dive, you find comfort in the, the lack of assurances, the lack of a single answer. It's the running art, right? It's the running medicine. Art of it all finding a solution for that runner, and I think the evidence plays a role, but you can't go in expecting the current literature to give you 100 percent of the direction. I think it gives us it gives us. the general direction, your clinical tuition, the runner needs to, the runner's presentation, the tissue tolerance, all of those things need to play a role. And ultimately you make the final decision on what's the best approach for yourself or the runner that you're, that you're treating. Um, and, um, you know, continue to adapt until you find a successful solution. My
Chris:favorite quote ever from biology class at some point was adapt or die, right? That's what we do, right? That's what I have to as biological species continue to adapt. And that's adapting your understanding, adapting your programming, adapting your biomechanics, adapting your strength. All right. Well, that's, that's kind of it for time, but I really love where this conversation went. And if you guys want to learn more, our running course is out there. Rich gives so much good science based, you know, recommendations based on this huge amount of literature that he synthesized. And I'm just there as a comic relief most of the time. So trying to give you guys, clinical pearls and apply it as much as possible.
Rich:Thank you for having me. This was fun having a chat and catching up on things. Uh, you know, the course has been, absolutely, uh, important part of my career and our relationship is as kind of running medicine professionals. I love teaching the course and have for many, many years that we've done this, um, our goals to. Is to give people the tools, um, to help runners. We, we want to keep as many of our patients, as many of our community out there and running and being active and enjoying themselves on the running trails. And I, uh, I hope the course gives you some tools to improve the success of those individuals. Yeah. So get out there, take the course, get
Chris:more systematic, get more streamlined, get more efficient and have fun doing it. All right. Thanks again, Rich. This is great. We'll talk to you soon.
Rich:Thank
Chris:you.
Thanks for listening. This episode was produced by me, Arpita and Krista Prado. Follow us on Instagram for updates and please like subscribe and rate the podcast to keep more episodes coming.