Running is a great activity for cardiovascular exercise and stress relief. It can also be a source of pain and injury. These injuries most frequently occur as a result of three major sources. First, running too much, too fast without working up slowly. Second, insufficient strength of the legs and core. Third, problems with form and the mechanics of running. A gait analysis can be performed to determine if there are running mechanic problems. Often brightly colored or reflective tape may be applied to several areas of the skin of the runner being analyzed to better help visualize specific anatomic landmarks during the analysis. After a warm up, cameras are used to record the running movements from different angles. The images captured are then reviewed frame by frame to determine if there are gait errors which may be contributing to pain or injury. Often multiple errors occur together. A plan is then created to help fix these errors with strengthening, physical therapy, and gait retraining.
Here we will discuss a few common gait abnormalities found. We will first address the abnormalities visualized from a side view and then a posterior view.
There are three foot strike patterns. A forefoot or toe strike, a midfoot strike and a rear foot or heel strike. Forefoot strike is most commonly seen while sprinting or wearing minimalist shoes. There is no conclusive evidence as to which of these patterns are best, but some studies have suggested that a heel strike pattern is associated with an increased risk of overuse injury. A forefoot strike pattern has been shown to increase the stress on the foot and ankle, while a rear foot strike pattern increases stress on the knees. When transitioning from a rear foot to a forefoot strike, be careful to not overstress the foot and ankle, as they are not accustomed to the increased stress over long periods.
The moment that the weight of the runner impacts on the outstretched foot is called the loading response phase. On frame-by-frame analysis this phase can be determined by the moment that shoe begins to deform after the initial contact. At this moment the angle of the tibia is assessed for excessive extension, which can exacerbate impact related injuries. A normal angle includes a vertical or flexed tibia. This angle allows the knee to dissipate the impact more easily.
During the stance phase, or the period of time where one foot supports the weight of the body, the angle of the knee of the planted foot is measured at the time of its maximal flexion. This angle generally reaches 45º although there is no specific cut off. If the knee flexes significantly less than 45º there is likely reduced shock absorption, which may be associated with tibial stress fractures and patellofemoral pain.
A common error is reduced hip extension of the trailing leg during late stance phase, or the moment before weight is transferred from the trailing to the leading foot. This finding often indicates reduced flexibility of the iliopsoas muscle. While there has been no defined optimal degree of hip extension, it can lead to many problems in certain individuals. When running at a faster pace it can lead to stride modifications in order to maintain the desired speed. These common compensations include increased lumbar extension, bounding to increase time in the air to make up for the decreased hip extension, and excessive reaching to increase stride length.
The preferred angle of the trunk while running has not been presented with strong supporting evidence. Generally, running experts recommend a forward leaning trunk. Increasing the trunk lean has been shown to decrease the stress across the patellofemoral joint.
Overstriding is when a runners foot lands in front of the person’s center of mass. On video it can be evaluated when the runner is in loading response. A vertical line is drawn upward from the medial malleolus to the height of the pelvis. This line should pass through the pelvis. If the line falls anterior to the pelvis it is an indicator of overstriding. An increased risk of tibial stress fractures has been found to be associated with overstriding.
Vertical displacement is found by determining how much the body moves up and down while running. This can be done by comparing the pelvis at its highest level during float phase, or the moment both feet are off of the ground, and the lowest point during stance phase. Increased vertical movement is found in “bounders” who often have decreased hip extension, as previously discussed. Reducing the vertical displacement decreases the impact forces on the body and the work required to run. Decreasing the cadence, or step rate, by 10% has been shown to significantly reduce vertical displacement.
Cadance, or step rate, is important to assess in all runners. By counting the number of heal strikes over 1 minute you obtain the “stride rate”, which when multiplied by 2 equals the “step rate”. There has been much debate as to the optimal cadence, and it is unlikely that there is an ideal number for all runners. Studies on running economy, or effectiveness while running, have show that a step rate of 180 is ideal, however this has not been backed by studies on injury mechanics. Decreasing the step rate by 10% was shown to decease stress in the foot and knee, decrease shin injury, and also help improve other mechanical running errors such as foot strike pattern, vertical displacement, and overstriding.
Base of Support or Crossover
When viewing a runner from a posterior view, there should be a small space between the feet during steps. This gap varies depending on the speed while running. When the feet cross over or overlap when the feet are planted it creates a narrow base. A narrow base of support has been associated with tibial stress fractures, iliotibial band syndrome, and causing other mechanical running errors such as excessive hip adduction and over-pronation.
Mild pronation while running is normal and helps to distribute weight across the foot evenly. Excessive pronation of the foot can lead to tibial stress fractures, patellofemoral pain, and Achillies tendonopathy. It is difficult to measure foot pronation using 2D video. However it is linked to heel eversion, which is easier to evaluate and can be used to determine the amount of pronation present. It is also important to determine that heel eversion is not occurring too quickly. Many shoes and orthotics have been marketed as a solution to excessive pronation. Currently the evidence supporting such products is inconclusive.
Many variables can impact the knees while running. Excessive hip internal rotation, hip adduction and excessive knee valgus, or angling of the knees towards each other, all have been found to contribute to running injuries. One way these variables can be assessed during a gait analysis is by evaluating the knee window. This is simply done by assessing if there is or is not a space between the knees at all times of the running cycle. A closed knee window can also be seen if there is excessive adduction, even if there is normal alignment of the hip, knee, and ankle.
Pelvic drop is often related to hip and core muscle weakness, specifically the hip abductor (gluteus medius, gluteus minimus) and hip extensor muscles (gluteus maximus, hamstring muscles). To assess pelvic drop the runner wears markers, which allow for visualization of the posterior superior iliac spine, or wear tight fitting clothes where the waistband can be used as a reference. When pelvic drop is present the pelvis will be fairly level at initial contact of the foot, but during stance phase there is a drop of the pelvis opposite of the foot contacting the ground. By strengthening hip abductors and extensors the risk of injury is reduced.
By Dallin Erickson, DO and Mo Mortazavi, MD
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