Exercise for pain - more about what you don't do?

Exercise for pain - more about what you don't do?

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Controlled trials of exercise for low back pain often suggest that the type of exercise doesn't matter.  And if you love "stability" exercises then these results can really challenge what you think and could even make us expert clinicians feel like we have less "special" knowledge...always challenging to be confronted with this.

FMS scores linked to higher injury risk in runners

Here is a neat study (abstract here) linking increased injury risk in runners with higher Functional Movement Screen (FMS) scores. You noticed I said higher? As in "better" scores were correlated with more injuries.  I will have to read the whole article and to be fair put just as much critical thought into the papers that showed a slightly greater risk of injury when scores were lower. But here is a quote:

Unexpectedly, higher FMS scores led to an increased injury risk in collegiate runners. It has been suggested that in order to maintain optimal musculoskeletal health, one must have variety in their movements and postures. Since runners do not get variety in movements from their sport/training, perhaps those with lower FMS scores are achieving that variability, and avoiding injury, through their more variable movement patterns.

I think they may be torturing a rationale out of their findings even though I agree with the sentiment.  I'm not sure that if someone scores higher on the FMS that they are naturally more variable.  I'd guess many people with high scores have wonderful control of their function and can move in a multitude of ways.

What might be the more obvious conclusion is that the score could be meaningless.  Injury is complicated.  Its just some statistical fluke. The same way a lower score gets associated with more injuries.  There is always a lot of variability.  And maybe screening in this manner just doesn't work.

If I take anything away from this it means if we are serious about injury prevention we need to look at more than just the physical or the "quality" of how someone moves.  Perhaps these screens aren't enough (groundbreaking, I know :) ).  And to the credit of every screen developer I know they say this too.  Where is the brave PhD student to do a the comprehensive screen that encompasses all aspects of a person's life that can contribute to pain and injury? Probably writing algorithms for high frequency trading and making a killing but that's another story.

Its OK to not know what to think of these things

The limitations of all movement screening and the FMS by default

Originally published at Medbridge Health (a great online CE source)

I've used movement screens in the past and still use movement testing of patients to look at how they move. If you use the Functional Movement Screen (FMS) you will probably pick up some limitations in how your patients move. Some of these limitations have even been linked to future injury in specific populations. The limitation of these “screens” is that they might not even be “screens” at all. A screen should catch everything (i.e. have more false positives and FEW false negatives) but I’m afraid that movement screening tests don’t actually screen for anything beyond the movement that you are testing.

I see two big concerns with movement assessment testing and screening:

  1. Can “screening” using very simple tests actually miss the movement “flaws” or “dysfunctions” that we are interested in?
  2. Does screening for “flaws” just expose normal human movement variations/options and are we too quick to label something as dysfunctional?

By far, the most popular and successful screen is the Functional Movement Screen (FMS). I respect the thought and great work that has gone into developing and researching the FMS as well is its clinical cousin the SFMA. The Selective Functional Movement Assessment can be seen here being taught by Kyle Kiesel. This post is not an attack on the FMS or other movement screens (MCS out of New Zealand for example). It is more about the limits of all of our tests in assessing for movement dysfunction, trying to predict injury risk and treating pain. Their work deserves a lot of respect and I intend to give it.

Some background on Physical Function Screening

“Screening, in medicine, is a strategy used in a population to identify an unrecognized disease in individuals without signs or symptoms. This can include individuals with pre-symptomatic or unrecognized symptomatic disease. As such, screening tests are somewhat unique in that they are performed on persons apparently in good health.” (Wikipedia)

Physical Function Screens have a few purposes:

  1. Identify individuals at a greater risk of injury based on how they move
  2. Give insight into how people move that is greater than the sum of its parts
  3. Give insight into the mobility or stability of specific body regions
  4. “Clear” certain areas of function. The screen functions as a “triage” to help the assessor determine where other assessments take place

The very strength of the FMS is its simplicity, which leads to its lack of sensitivity

Injury Prediction Limitations

The ability of movement screening to predict injury has been dissected numerous times with much of the research being conducted by the creators of the screen. A review of the research on the FMS can be seen here and an interesting podcast discussion can be heard here. Injury prediction is so complicated and difficult, it is not really fair that we ask the FMS or other screens to be able to do this. Rather, as its creators suggest, it should be part of a complete battery of testing. I would go so far as to suggest that instead of using simple screens of physical function, we need to expand the screen and delve into all the parts the make up all the movements, plus a battery of tests addressing the entire human (e.g. cognitions, psychosocial profile etc). So if a movement screen becomes part of a battery of testing, is it really still a screen? To me, it just becomes another series of good tests that provide some information. If you expand your screening to include other more detailed tests, do you still need that screen? To me, each test in the screen now becomes valuable in its own right but NOT as surrogates for other realms of function.

Limitations associated with current physical function screening

Screens must be Sensitive

Perhaps the screening test itself is not that important. It is what the screening test exposes that is important. It is the alteration in form or the movement anomaly that we are looking for. We assume that there are better ways to move, and certain flaws will increase our chance of injury. So to be a good screen, a test must expose the “flaw” assumed to be related to injury. This is where I feel most screening tests can miss things. They miss some limitations in function. Some examples:

Limitation #1: Screens can miss simple aspects of altered function

Let’s just assume that limited ankle dorsiflexion is a risk factor for injury in runners. A screening protocol should expose that flaw. Most screening battery tests use some form of squat test to look at this function. The FMS uses an overhead squat test. If the athlete cannot squat to depth without significant back rounding or the arms coming forward, it is assumed that something is wrong. The FMS does not tell you why that person can’t squat. You now have to do breakouts and see if they have limited hip flexion, poor thoracic extensions, a motor control issue or perhaps limited dorsiflexion. You then go and do additional testing to figure out which it is. The problem here is you don’t need a lot of dorsiflexion to squat deep if you have good lumbar and thoracic extension, if you have a greater proportion of anterior body mass relative to your lower body (think toddlers, their big heads balance their butts). Here is a case where the screen misses the flaw that we want to find. This would hold true for most other testing in the FMS as well. You would have to add the Y-balance scale to give a better idea of ankle dorsiflexion. The tests are still great because they tell us something is not right with the movements, but the job of screening is to be comprehensive.

Limitation # 2: Screens can miss movement flaws even in similar tasks

I like the single leg squat test. I think it gives me insight into how the hip controls the knee. I like to think that it might also give insight into hip strength, control of the knee during running, or control of the knee during jumping. The problem is it probably doesn’t. Same holds true for an overhead squat, a lunge, or a step-over test. My favourite screening test is not that good of a screen because it may not tell me about the flaw I am trying to expose (dynamic knee valgus during sporting activities). I have 3D kinematic equipment for analysing runners. I would guess that more than half the time a runner has increased hip adduction during running, they will have normal hip adduction during the single leg squat.

Limitation #3: Lack of transferability with load and speed

One good thing that the FMS has always taught is that movement testing is more than the sum of its parts. It gives insight into how people choose to move (motor control) that can’t just be predicted from manual muscle testing or joint goniometers. What we have seen lately is this lack of consistency between table tests and movement tests may be a double-edged sword. Meaning, the tests we perform in the clinic (e.g. squats, single leg squats etc) may not reflect how someone moves in their ADLs, in their sport, or under different load and speed conditions. David Frost and Stu McGill highlighted this in their paper here.

To me, the point of the tests are to expose flaws. If a single leg squat test or any tests of the FMS miss a flaw that occurs during other functional tasks, then that test is not a screen. It missed the flaw. Screens by definition are overly sensitive. You should have way more false positives than false negatives. The screening tests might only tell us about how an individual performs that test, nothing about their movement at other times and in different contexts. It still provides valuable information when the athlete fails the test, but it’s not a screen.

Limitation #4: Screens aren’t surrogates for assessing all aspects of joint function

If I recall correctly, one of the points of using movement assessment tests was to get away from simple tests of muscle strength or endurance. However, I often hear utilizers of screening tests suggest that someone fails a screen because they are weak in the hips or spine or that they don’t have “stability”. Hell, I thought this myself. A poor single leg squat means you are weak in your hips right? Nope. We assume that if a pelvic tilt occurs, there might be weakness in the hip abductors. Amazingly, this isn’t related. A recent paper paralyzed the hip abductors (mirrored in a similar paper here) and there was no change in hip kinematics suggesting the Trendelenburg is not a good screen. A second paper assessed the one leg squat and found that hip adduction was not correlated with hip strength. If we think hip strength, in and of itself regardless of movement technique, might be protective of injury our screening tests miss this. We therefore need more tests. The hip adduction motion in that study was correlated with Gluteus Maximus recruitment suggesting that movement pattern was a motor control issue (as the FMS people consistently teach), thus the test still has value in and of itself. It’s just not a surrogate.

We know that movement screens aren’t surrogates for tests of performance or for tests of joint strength, ROM, etc. Isn’t some of this information important? Is core endurance important for your athletes? Is the ratio of hip abductor strength to adductor strength important in hockey players? Do you want high levels of strength in the hip abductors of running? Probably yes. Movement screens give no insight into this. If you simply leave your testing at the level of the screen you miss this information.

Failing a single leg squat test (or a lunge, overhead squat etc) can still be valuable. I won’t throw these tests totally out. But now they just become tests and not screens. I would argue that a movement “screen” is really just a test separate to itself. Those movement assessments are independent entities. Addressing those tests specifically might be valuable. But I can’t say that the test is a surrogate for other functions and for other contexts. Thus it is limited as a screen and is just another test.

Stop being so critical – Screens are still helpful

It’s not fair or just to only point out limitations. I use parts of all of these movement screening tests. The ideas behind the movement screens (i.e. the flaws they expose) even help me create my own (e.g. every exercise can be an assessment). I’ve suggested that movement screening might miss movement flaws, give basic information about strength/endurance, and not always accurately test the mobility of joints. But the tests themselves do tell us something. If someone “moves poorly” on a test in an unloaded position, we could argue many times that they certainly can’t do that type of movement under weight or speed. These tests certainly give information about how people choose to move. That in and of itself could be valuable for exercise prescription.

Alternatives to physical function screening

Make testing less about the test and more about flaw. Test for comprehensive capacity. We need to know more about what physical limitation or form deviations are predictive of injury for different sports, activities, and people. For example, if we think that lateral spinal tilting is a risk factor for injury in a certain sport, then our job is to try to expose this risk factor. The FMS can be a great launching pad for that. But don’t just stop when someone has “passed” a test. If you agree that the screen might be capable of missing something, then you have to test everything. If you agree that the screening tests might not reflect what happens to function during when load or speed is placed on the body, then you have to modify the tests to try to expose these flaws under those conditions. If your athlete is a runner, then your screening test should be running. You can make up your own screens. Your job is to expose flaws.

The limitation of all movement testing: When is a “flaw” a “flaw”

I use the word flaw like it’s a given. We assume that certain movements are more related to injury. Unfortunately, the research is not that robust. Our biggest difficulty and challenge in research and in the clinic is to figure out when a “flaw” is truly a flaw that increases the risk of injury. One alternative to viewing movement “flaws” as flaws is to view them as different movement options. You’ve seen these people. People who move with “terrible form” yet still perform well and are injury-free. How do they do this? Perhaps they are well trained to tolerate those positions.

Take Home Points

  1. Movement screens probably aren’t best viewed as screens since they lack sensitivity. Movement screens are good at exposing how someone chooses to move during specific tests. Unfortunately, we can’t generalize these movement patterns to other contexts. So in effect, passing a movement screen only tells us that the flaw we are hoping to expose doesn’t occur during the test, but can still occur during everyday movements.
  2. Movement screens aren’t surrogates for other areas of physical function. Screens aren’t well correlated with spine “stability” measures, trunk endurance/strength, physical performance, or basic measures of joint kinesiology. All of these metrics may hold some value in injury prevention.
  3. Perhaps movement screens should just be viewed as movement assessments in their own right. If they lack transferability to other tasks and aren’t surrogates for other functions, then we should view them as distinct. There can still be value in seeing how someone moves during these tests (they are now tests and not screens).
  4. You can make up your own movement assessments: the ideas behind the screens (i.e. exposing a “flaw”) in movement can be useful. If you believe that flaws/movement dysfunctions are relevant to injury risk or current injuries, then every test, movement, exercise, or performance can be an assessment. Learning from the professionals that teach the FMS can be helpful in you creating your own assessments. Go buy the book Movement by Gray Cook. It’s very well done in terms of teaching, pictures and explaining their rationale.  You can disagree with them but I think its very important to still respect their work.

- See more at: http://www.medbridgeeducation.com/blog/tag/greg-lehman/#sthash.saUWeIUf.dpuf

Text-Neck is bad science and fear mongering

text neck is not an epidemic

There are a few issues with the concerns of people reading their phones with their neck flexed.

  • it ignores a great deal of biomechanical research showing a very poor correlation between posture and pain
  • it ignores the research showing that neck pain is so much more than physical loading on the spine
  • it ignores our bodies ability to adapt.  When we load any body part it adapts.  This is how runners can run marathons.  Loading (or pounds on the neck) is good
  • if you are worried about text neck than you are ignoring the activities that have had humans bending their necks for centuries.  Reading books, playing chess, looking down at the sidewalk, knitting etc all require the neck to flex.  Where is the outrage in the media against knitting?  Against chess? We have always bent our necks it is what we are built to do
  • the conclusions ignore the sporting activities that have huge amounts of loading but are good for the spine.  Cycling, heading in soccer, headstands and golfing all create large loads on the neck.  Provided people slowly and progressively ease into these activities we can adapt.

The problem with text-neck is the same problem as any other prolonged position.  We are meant to move.  If you hold your head in ANY position for prolonged periods it is likely that you will feel pain.  Ask a soldier on parade.  That ideal upright position is a real pain in the neck.

None of these criticisms imply that the cervical spine is not stronger when in neutral.  If I were to do a headstand I would not flex my neck.  However, heavily loaded positions are different than simply bending your neck.

Some notes on the actual paper (link here)

Its quite difficult to fully critique this paper as the Methods section is incomplete.  A methods section should allow you to reproduce the paper.  This paper does not provide that. The results are not put into context.  What does 60lbs of force mean?  Is this 60 lbs of compression through the vertebral bodies?  Is the force shear? The results are not presented in a manner consistent with biomechanical studies.

Here is the methods section (please go ahead and recreate the study)

"A model of the cervical spine was created with realistic values in Cosmosworks, a finite element assessment package. Calculations were made and then forces were extracted in newtons and then converted into pounds. We made the calculations using neck + head, which gave an average weight of 60 newtons (6kg or 13.2 pounds). The center of mass was located 16cm above C7 or 15cm from the top of the skull."

The results of the study (if they are valid which can not be assessed) need to be put into context. What are the loads through the spine during other daily tasks? What is the failure tolerance of the cervical spine? Other research has suggested the cervical spine has more than 45% the compressive strength and 20% the bending strength  of the lumbar spine (abstract here).   This compressive value would exceed 450 lbs.  If the authors are measuring compression (which again we don't know) then you can see that 60lbs is not that big a deal.  Why did the authors not discuss this paper?

A much better paper that explores the complex inter-relationships between pain, posture, psychosocial factor, physical anthropometrics can be seen here.  What you notice is that posture is poorly correlated with pain. Not even that well correlated with pain never mind actually causing pain.

So why do I care and whats the harm in these reports

First, they are just wrong or at least not very complete.  I think there is value in trying to be a little less wrong.

Second, what does it say to patients when we tell them how terrible certain postures and that they need to adopt an unvalidated, assumed "ideal" posture? To me it supports the idea that the body is weak and that it only has this small range of optimal function (e.g that ideal head position).  I view the body as robust and strong.  Capable of adapting to the stresses we place on it.

Last, when patients are in pain they are often afraid to move. Again, they view their body as weak and fragile.  Which it is most often not.  It is certainly sensitive.  Providing unnecessary rules about how to move, about positions to avoid and advice that creates this sense of fragility can increase pain, hypervigilance, lowered self efficacy and increased catastrophizing - all associated with pain and disability.  Patients need to learn their strength.

Is there anything good in these reports?

There sure is.  If we reconceptualize our views on posture and recognize that any posture that is used repeatedly/prolonged and that we aren't accommodated to might increase the sensitivity of our system then perhaps there is a good message in there.  But this is not the same as saying we need to always stay near an ideal.  Instead look for variety, build tolerance, build confidence and develop capacity.

Sample lectures, interviews, podcasts and more

Presentations Presenting at the APTEI 2014 Symposium: How faulty biomechanical reasoning may increase pain and disability.

Medbridge Health Breakouts: Where does Biomechanics Fit?

Interviews

1. with strengthandconditioningresearch.com on Pain and Injury

Podcasts

1. The Runner Academy: Running injuries, posture and treatments.

2. Healthynomics.com  Getting Started with Running.  Strength training, form and pain management

 

Free E-books

1. Form, Footwear and Footstrike: Implications for running mechanics and injury. A very rough ebook from a lecture on the same topic

2. Golf Biomechanics - The Kinematics of the Golf Swing: e-book

Running Strong: Video Analysis, Running Re-education and Strength and Power Program for Runners

The Running

Strong Program

What is it?

A 4 session program to improve your running and decrease your chance of injury.

What is it composed of?

  • Detailed analysis of your running history and programming to find predictors of injury
  • High Speed Camera (240 frames/second) analysis of your running form
  • Pelvic Drop
  • Detailed functional evaluation of your physical function designed to find weak links
  • Custom created corrective exercise and performance based exercise program including 3 follow up sessions

Is it covered by insurance?

 

Yes.  I am both a physiotherapist and chiropractor.  Each session can be billed separately and our rates are well within the normal fees charged for regular physiotherapy sessions

The cost?

$400.00 for the initial 1 hour session plus 3 follow up sessions.

The timeframe?

The timeframe is surprisingly flexible.  Some people need a follow up session within a week of the initial evaluation.  Others might need a follow-up session within 3 weeks.  Having this flexible time frame allows us to tailor the program to your needs.

Can I work with my existing coach or personal trainer?

Absolutely.  In fact, this is encouraged.  I regularly work with running or triathlon coaches to create safer and better training programs.  If you already work with a personal trainer we can speak with your trainer about encorporating the running performance program into your existing exercise sessions.

About Me:

I am physiotherapist and chiropractor with a MSc in Exercise/Spine Biomechanics.  I have published more than 20 peer-reviewed academic papers on exercise science and injury.  I regular work with runners and multisport athletes from beginner's to Olympic athletes.  I currently write injury prevention articles for Triathlon Canada.  I am also an instructor with therunningclinic.ca - Canada's, if not the World's, leading course on the prevention and treatment of running injuries.  Last, I am the clinical director of Medcan's Run Well 3D Kinematic Analysis Program for Running Injuries.

Related Posts

1. Running Strength: Moving beyond the Core

2. Running Biomechanics: Clinical decision making in running analyses

3. Gait Modifications for Runners.

 

Clinical decision making in running form interventions: implications for injury

hip-adduction-and-knee-abduction.jpg

Clinical Decision Making in Running Form Interventions Initially written for Medbridge Education

The purpose of this article is to highlight the clinical decision making process during kinematic running analyses - focusing on evaluating the kinematic risk factors for running injury and not kinetics.

Both predictive and correlational research attempts to identify kinematic variables that are associated with an individual’s future or current injury.  Many of those being:

-higher levels of pronation or pronation velocity

-abductor twist

-increased tibial internal rotation

-increased knee abduction

-increased hip abduction or hip internal rotation

-pelvic drop

-stride rate

All of the above variables have been either documented as being elevated in runners with injury (correlated) or have been found to be precede the onset of injury (longitudinal research).  As with most human function nothing is that straightforward though.  To confuse us, all of the above factors have also been shown to have NO relationship to injury in other studies.  We now have this dueling evidence base where it is very easy to cherry pick research supporting our ideas.

Pain and injury are multifactorial – simply suggesting that an injury is due to altered kinematics ignores the wealth of research highlighting the many variables that influence the pain experience. Thus, our clinical decision making is never as simple as finding a “flaw” and assuming that that is the driver of the injury.  So how can we view these “flaws”?

Kinematic flaws and how we interpret them can be divided into three categories:

  1. Defect: the kinematic flaw is a deficit in function leading to a future injury or pain
  2. Defense: the kinematic flaw is not a flaw but is only correlated with the injury.  The altered movement itself may be driven by nociception and is a consequence of the injury or pain.  The kinematics may be driven by protective motor output
  3. Red herring: the flaw is not a flaw but merely an expression of the large amount of functional variability that exists across people.  The flaw preceded the injury and will remain even with changes in pain.

Injury is the failure to adapt stress

To determine the significance of a kinematic flaw a few assumptions regarding the nature of injury and pain are necessary. These are naturally open to debate.  First, injury and pain should not be conflated.  Runner’s can have tissue anomalies that many might view as pain (e.g knee OA, hip labral tears) and have no pain.  They can also have pain with no evidence of disruption in connective tissue.  Pain can be viewed as the brain’s response to the perception of a threat. With many factors (cognitions, past experiences, expectations, emotions) influencing the brain’s decision to output pain – nociception created by mechanical deformation of nervous tissue being just one.

With runner’s all of these factors can be viewed as stressors inputted into the system.  An ideally adapting system (at least for those who want to run pain free) would be one where the brain does not output pain.  Pain occurs when some immeasurable threshold is reached where the brain perceives a sufficient enough threat to output pain.  An injury can be viewed as the body’s failure to adapt to the imposed loads that exceed the threshold for positive tissue adaptability.  It is assumed that both the body and brain have the ability to positively adapt to imposed demands or loads. It assumes with appropriate and graded loading that both our connective tissue strength and our pain thresholds can be improved.  Injury-free and pain-free running require us to stay below these thresholds.

How kinematics might contribute to pain

Altered kinematics may either create an initial noxious event leading to nociception, may contribute to nociception by continuing to sensitize nervous tissue or may even indicate a movement habit that a runner has fallen into and nociception itself does not need to be present.  This habit of movement may even, to quote Lorimer Moseley, “facilitate protective neurotags”.  What might initially have been a movement flaw that helped the system (e.g a defense) has now become associated with pain that has no further value.  Our conundrum as clinicians is not determining whether the altered kinematic is cause or consequence of pain but rather determining if there is value in trying to address it.

Is this a flaw?
Is this a flaw?

How and when to address Kinematic Flaws

After we perform a running analysis we might find a number of kinematic variables that might be related to injury.  The flaws we see pose two questions:

  1. Can the kinematic flaw be reasonably linked to the runner’s pain or injury?

Going back to the assumption that injury or pain may occur when the demands on the body exceed its ability to adapt can we suggest that the kinematics measured might load the area of injury to such an extent that mechanical pain would occur?  If a patient presents with medial leg pain, appears to pronate a great deal and the speed of that pronation appears elevated we might be able to suggest that those variables relate to the pain as biomechanical link of increased tissue strain can be made.  This idea can be bolstered with post-hoc reasoning if simple interventions that might address the flaw (e.g taping an arch, running with a wider step width) positively change the pain experience.  This thinking would be bolstered by some research that supports this link.  But wait you naturally scream at me, there is lot of research suggesting pronation has no relevance to injury.  This is absolutely true and leads us to a second question.

  1. What factors can mitigate or amplify the relevance of this flaw?

Rather than increased pronation and increased pronation velocity being interpreted as a defect we might argue it is merely a red herring.  We see this in a number of elite runners with massive amounts of pronation and massive amounts of mileage and speed.  Yet they have no pain.  What factors might mitigate the proposed risk of having this assumed kinematic flaw?  Could those with what appears to be a running kinematic flaw have adapted to this ‘flaw” over time?  Have they progressed their mileage slowly over years?  In some instances, flaws aren’t flaws.  The runner is fully adapted to that gait style.

On the other hand, a novice runner may exhibit running mechanics sometimes associated with injury.  She may be able to run pain free for awhile until suddenly pain develops with no change in her training.  There has been no change in the loading placed on nervous tissue yet pain is experienced.  A possibility exists here that the sensitivity of her system was changed.  Thus her threshold for pain or injury was decreased.  Since multiple factors influence this sensitivity it is important to attempt to address those factors.  One such intervention would be to address the mechanics of her gait.

Strategies to address Kinematic Flaws and Pain

What’s great with treating running injuries is that we don’t always need to change the kinematic flaw.  We have a number of studies showing that gait retraining can change both pain and running kinematics but we also have research suggesting that interventions can result in changes in pain with no changes in kinematics. In the latter instance, we can use the altered kinematics as a starting point in creating our therapeutic interaction.

At it’s most basic, treatment is merely the modification and judicious application of stress.  The following two-step and not mutually exclusive approach can be used:

  1. Desensitize and Unload
  2. Increase tolerance to stress

Desensitize and Unload

Much of what a manual therapist does would fit into this category.  Again a multifactorial approach may be necessary.  Interventions may be pain physiology education, education about tissue and nervous system adaptability, taping, temporary orthotic use, gait retraining, manual therapy, movement therapies and alterations in training loads.

Increase tolerance to stress

I believe most runners can keep running.  In fact, they need this stressor to adapt.  If we teach runners the importance of the adaptability of their system then they will understand the importance of a graded return to activity. Gait retraining would also fall into this category but it should be remember that gait modifications primarily redistribute forces during running.  Thus a slow return to running with a new style is advised to again allow for the adaptation to the different stress.  Last, we can use kinematics as a window into prescribing capacity or motor control exercises.  Resistance training can be justified in running injury treatment both as a pain modulator and under the idea that a tissue’s response to loading can be improved – increasing injury threshold.

A future post will elaborate on the clinical decision making of these interventions. A helpful course on understanding running biomechanics and injury can be seen in this link.

Summary

We don’t know the ideal way to run and by extension we don’t know what are true kinematic flaws in running.  We know that pain and injury are multifactorial and taking this big picture view of rehabilitation is helpful.  Identifying what may be kinematic flaws can still provide a window into interacting with a patient.  Addressing kinematic flaws, along with a runner’s clinical presentation, through a multimodal approach (e.g. desensitization, education, gait retraining, exercise selection, activity modification) is a comprehensive approach that recognizes clinical uncertainty.