Clinical decision making in running form interventions: implications for injury


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.


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.

Strength first, core last: Modifying core training for runners

front bridge from knees
front bridge from knees

Don't get me wrong.  I love respect the core. But you can't open a running book, magazine or blog without hearing how important it is for runner's to train the core.  I agree with this to some extent but for 10 years I have advocated for three points to keep in mind when it comes to runners and core training:

1.  Core training should come second to a general strength and power training program.

2.  You can adequately train your core without doing a bunch of traditional core only exercises.  This is a whole blog post that you can see here.

3. If you are going to focus on the core consider training for strength and do less endurance core exercises (if you do 5 minutes or more of continuous planking then I'm talking to you).

Point 1. General strength and power first

Despite the core's dominance in the sports medicine field and popular culture there is very little research that basic core work actually improves running performance, improves posture or makes you more efficient.

A couple of studies show an improvement in running performance (here) with one showing no change.    A slightly related review on core training found only marginal benefits of core stability training to athletic performance.  Lest anyone think I am going out on some Maverick limb here and that I'm a contrarian-prick my thoughts have been mirrored in other published reports questioning the benefits for simple core exercises for athletic performance.

I recognize that a lack of evidence does not mean we should stop training our core for runner's but when we have a huge amount of evidence for another intervention and a limited number of training hours then we should allocate our training time accordingly.

Guess what research dwarfs the core research?

deadlift start1
deadlift start1

Lower body strength and power programs.  There is a huge body of research showing that heavy strength training or power training (e.g. plyometrics) improve running economy and race performance.

Here area some blog posts and a few research papers:

1. From Tom Goom the running physio: resistance training for runners.

2. From the sports physio Adam Meakins: should endurance athletes do weights?

2. Maximal strength and explosive strength both improve performance

3. Training heavy improves performance

4. Strength training superior to endurance strength training for performance

5. Strength training again superior to endurance strength training for performance

6. Ten year old research (nothing is new) showing improvements in running economy after heavy resistance training

7. A systematic review suggesting improvement in running economy

The theme in the above studies (and they are just a small sample) is that maximal strength training is either superior to endurance-strength training (i.e doing more reps of a lighter weight) or just as good at improving running economy.  Meaning endurance athletes should stregth train and lift heavy.  Explosive training (often plyometrics) are also beneficial in improving running economy. There is no research saying we should not be strength training.  So get off your planks and grab a bar.

Why is the core not of extreme importance?

The hips and the calves produce power and should be treated as supreme

The trunk muscles (erector spinae, obliques, rectus abdominis, transverse abdominis)  aren't the primary drivers of locomotion in endurance athletes. They are important they just need to be put in their place.  This is not an all or none thing but they take a back seat to the legs and hips during running and our training should reflect this (see Tim Dorn's research here and here, an old post of mine here and Sam Hamner's research here and here).

2. You can train the core without actually targeting the core

I want to reiterate - the core is still important.  No part of the body should be neglected. But perhaps there is a more efficient way to train the core. This was my big research thesis 7 years ago that was quashed with all my other mediocre research dreams when I was pushed out the door of chiropractic college I worked at :). In our pilot work we were seeing trunk muscle EMG activity during squats, deadlifts, cleans, jumping, pull ups, pushups etc that was comparable to the activity seen during traditional core exercises. It wasn't as high as we thought but it was still comparable to standard core exercises (The reason it was not as high as we predicted was later explained in an excellent paper by Stu McGill here)

You can read an entire post on this topic here.  But the take home point is that exercises like the deadlift, squats, push ups, kettlebell swings, kettlebell snatches, Olympic lifts, probably pull ups, probably jumps and sprinting train the core to comparable levels as basic core exercises do.  Yes, you can certainly focus on weaker areas with basic exercises and you might want to do this if you are working with someone doing corrective exercise work but for the average runner you get a lot of bang for your buck when doing compound strength exercises.

#3. Train the core to get strong - stop doing "tempo" only core workouts.

See Bret Contreras to get strong
See Bret Contreras to get strong

When you are running your core muscles work less than 30% of their maximum.  So in effect, running is a core exercise to train the endurance ability of your trunk. If you run 6 days a week for an hour that is 6 hours of core training.  Simple adding 10-15 minutes 3-4 times a week of basic core exercises does not really add much to the endurance ability of your abs/trunk.  You need to do something different and stress your trunk to a greater degree.

If you are doing more than 3 minutes of continuous planking what energy system are you training?  If you are training 10-15 minutes of gut-busting plank work 4-5 times a week what do you think you are doing?  Would you ever just do 200 squats in a row and assume this helps your running?  No. Yet this is what these drawn out core endurance exercises are akin to.  Would we ever train other body parts like this?  Would you do 5 intense tempo sessions a week and nothing else?  Why train your core like this?

Gut Busting core plank sessions are really "tempo" runs for your core

side profile lead pack3
side profile lead pack3

I think there is still some benefit in those brutal core workouts that you do where you work hard for 20-30 minutes. To determine its value you need to compare it to the quality workouts that make up the running you do in a week. What is that gut-busting workout akin to?  You work intensely for 20-30 minutes - does it sound like a tempo run? Would you do 4-6 tempo runs a week? No way. Thus, we should train the core the same way.

Your running provides endurance training stimulus for your core, your gut busting plank/trunk work is your tempo/quality work (1-2 times a week). If we stay consistent with our exercise training principles we should only do gut-busting core work at that anaerobic threshold level one to two times per week.  This leaves us with one more workout.

To have a fully comprehensive and balanced workout regime you now you need to add some power and strength to your core work.  We do the same thing with your lower body so lets do it with your core.

An alternative to your "tempo" core workouts

If you have trained your core for a long time its time to mix it up and get strong.  This might be the component that you are missing because you are doing too many "tempo" core workouts.  Training for strength or power may be the attribute your core needs to become well rounded and make you a better runner.  The mechanism for a core helping a runner can't just be about endurance.  Because if it were than just running would be sufficient.  The mechanisms for improving running by training the core may be explained by other neuromuscular characteristics that develop from strength training.  If so, we need exploit these.

Some suggested exercises to increase the strength challenge of your core.

1. Staggered Pushups

2. Ab wheel rollouts

3. Bridge Walkouts

4. Dead lifts

5. Side Bridges with leg lifts

6. High Knee Drives

7. Jumping tuck jumps

8. Medicine ball slams and throws


This is advanced.  You need to progress to this work.  That's where basic core exercises are good.  You progress as those basics become to easy.  Don't just do more of them.  If you squat 135 lbs for 8 repetitions when you start strength training nobody expects you to still do 135lbs 2 years later but now for 30 reps.  That is akin to the 5 minute plank.

A great article which shows how to do a number of excellent core exercises was recently written by Ben Bruno.  You can see the article here at T-Nation.  His writing of this sure saved me a lot of work.

Take home points

1. You should strength train and put more emphasis on general strength training than just your core

2. Many basic strength training exercises also train the core

3. Decrease the number of gut busting/tempo core workouts to 1-2 per week just like you do with quality runs

4. Basic running provides the stimulus for endurance adaptations in your core just like all your other systems

5. To train at true comprehensive capacity and be well rounded your core workout should also address strength and power not just endurance and speed-endurance.

Further Reading

1. Here is a nice complimentary blog post by Physio Tom Goom on training your core for running