Part II: Running and Low Back Pain- Exercises

Photo Credit: Scott Webb

Photo Credit: Scott Webb

In part 1 we discussed what researchers have found to be the top risk factors to low back pain. Quick summary: poor trunk stability results from muscle imbalances which excessively challenge the surrounding muscles and structures that support us.  When it comes to explaining low back pain, it helps to break the anatomy down in 3 basic areas. All of these 3 components marinate together in order to provide us with all the stability necessary to function well. 

First off, bones and ligaments are the basic "foundation posts" of our body. They provide basic and important stability to our whole body. Self evident that without our vertebrae and ligaments, we'd be in a whole lot of trouble.  Secondly, muscles that surround the spine  provide the most stability. Our trunk muscles need to demonstrates both power and endurance in order to provide stiffness at each segment of the spine. Muscle endurance become especially important in order to carry out prolonged and stressful activities such as running. Lastly, neural control is undoubtedly crucial for spine stability because our bodies need to be able to not only properly active  our trunk and spine muscles but our nervous system needs to beautifully coordinate muscle activity and timing appropriately to expected and unexpected forces (1,2). If all of these 3 components work as they should, there is a very high change that you will be able to compete and train with a lower likelihood of developing any low back injuries. 

Usually for someone to develop back pain, there tends to be a deficit in more than one of these areas mentioned above.   A common one being, poor motor control or poor muscle strength and endurance lead to excessive load on the tissues causing pain, especially after prolonged and repetitive stresses.

So how do we correct deficits and improve function and pain? A lot of research has looked into exercise and training and its affects on pain and function. In a 2004 review of articles, the authors concluded that exercise helped decrease pain in improve function, so that is GOOD news for us active people- more exercise ! :)  (3,4,7)

In my clinical opinion, I try to remind my athletes that in order for you to run and stay pain/injury free you have to be fit. Running is not easy on the body, I have previously stated that the body has to tolerate 3x our weight each time out foot touches the ground. That means our joints all the way from our neck down to our ankles have to stabilize our heavy limbs each step of every mile. 

So let’s tackle each of the 4 contributing factors of back pain (I presented in Part 1 of this blog series) with some exercises you can implement.

Deficit #1:  Weak Lumbar Extensors

According to McGill norms for trunk extensor endurance for males is about 161 seconds and for females 185 seconds, plank norms for athletic men 120-180 seconds and athletic women 90-120 seconds, and side planks 60-90 seconds for athletic men, and 75-86 seconds of athletic women. Therefore, if you find that you are not even close to these norms- you should work to get there!

The muscle we are targeting here are the multifidus and quadrates lumborum.  

1.   Bird-Dogs:

  • Get into a quadruped position: hips over knees & shoulder over hands
  • Begin by tightening core, keeping spine neutral (avoid rounding or arching)
  • Extend one arm and opposite leg outward simultaneously- MINIMIZE trunk rotation. 


2.  Side-Plank: 

  • Lay on your side- onto your elbow - place the top foot onto of the bottom foot and  straighten both legs
  • Engage core and Lift your body off the ground- there are only 2 points of contact, your elbow /forearm and the side of the bottom foot
  • Hold - 30 seconds bouts 

3.  Supermans : 

  • While lying face down, slowly raise your arms and legs upward off the ground. - keep your chin tucked- hold for 5 seconds
  • Then lower slowly back to the ground- you will feel your lower back work! 
  • bouts of  1min x 3 

Deficit #2: Delayed Activation of the Transversus Abdominis.

Many studies focus on the just the Transversus Abdominis (TrA), which is true it is dysfunctional in patients with low back pain. I will throw in here that many times it involves the obliques, and the diaphragm.

Before you even begin progressing exercises for the abdominals I  HIGHLY recommend working on  Diaphragmatic Breathing and proper Core Engagement- and this my friends is NOT EASY, particularly for those who are new to consciously thinking and operating properly through activities they have taken for granted. Correct exercise follow below: 


Diaphragmatic Breathing: ( creating intra-abdominal pressure IAP)

  • Start off laying on your back with your knee bent or sitting.
  • Cup the side of your trunk with both hands or use a belt. 
  • As you inhale think about filling your abdomen and filling the whole abdominal cavity;  you can also try to think about pushing your stomach in all directions as you inhale- you should feel both thumbs and fingers being pushed out. 


  • Gently exhale with lips pursed to create tension and repeat. 

Sahrmann Core Exercises Level 1,2,3

Level 1: 

  • Lay on your back with knees bent, low back flat against the ground , ribs tucked down 
  • engage core- and without arching back lift one leg into the air followed by the next 

Level 2: 

  • Start out with both legs floating in the air at 90 deg 
  • engage core, without arching back bring one leg down and slide it out and slide it back in and switch 


Level 3:

  • Start out as in level 2
  • this time instead of sliding a foot out, you will float the whole leg out.- WITHOUT arching the low back or flaring the ribs. 

all done until fatigue- or break down of form. You should NOT feel your low  back working/burning.

Deficit #3:  Weak Gluteus Maximus:

The GLUTES!!! The mighty glutes. Yes, you would be surprised as to how many runner DO NOT incorporate staple glute exercises. Our hips are what are suppose to power us forward. If anything we do need strong glutes as well as strong hamstrings and calves. For the most part, it is more common to see over dominant hamstring vs over dominant glutes. Having strong gluten will also help reduce some hip flexor stiffness because powerful hip extension will promote less pull from the leg. 

When you start doing exercises: you have to progress from non-weight bearing exercises to weight bearing exercises. 

Non Weight bearing: 


  • For both versions- you will use a theraband for resistance- place around the knees
  • Get into a sidling position and slightly role the whole body forwards 
  • Keep your heels together and lift the top knee towards the ceiling- make sure you feel the gluteus burn after a few repetitions- NOT the side of your leg/quad/back/or hamstrings.
  • Advanced- Clam with Side-Plank ( see side plank bone and add Clam movement)

Non-Weight Bearing:

Squat with Band

  • Place band around knees- stand shoulder width apart- and push band apart
  • Begin to squat down- thinking about sticking hips out as if reaching far back for a chair
  • Maintain the tension of the band around the knees by pushing as as you squat down

Firehydrant: ( really difficulty exercise FYI, need good balance and core strength)

  • Place band around the knees, and balance on one leg
  • Hinge through the hips- stick butt out and slightly bend the loaded leg
  • Engage the core and slowly rotate floated knee out towards the side
  • DO NOT LET trunk or hips rotate-
  • Hold for 1-2 seconds and slowly return to the start and repeat 

Deficit #4: Stiffness of Hip Flexors: 

The hip flexors role are to bring the knee up. As runners we do this thousands of times. A lot of runners will have some sort of stiffness. Some more than others, and if your hips are too stiff it will create an anterior pelvic tilt and result in increase stress at the low back.

Stretching your hips along with implementing hip extension exercises as demonstrated above will help keep everything as balanced as possible.

The one stretch I always teach is the kneeling hip flexor stretch.

The trick to this is tucking the hips before leaning forward!

Kneeling Hip Flexor Stretch

  • Get in kneeling position
  • brace core and tuck your butt/hips under 
  • Gently lean forward with your hips first 
  • hold for 15 sec and back off total of 2 min per side. 
hip flexor bad .jpg
hip flexor good .jpg


  • Recall that usually if you are having back pain, the cause will most likely be a combination of deficits if more than 1 area! 
  • If your back pain is getting worse and affecting your training and performance see your local Physical Therapist - and get going on the right path. 



-Your fellow runner, 


Doctor of Physical Therapy 




Blog edit: Amir Medovoi





1.     Barr KP, Griggs M, Cadby T. Lumbar Stabilization Core Concepts and Current Literature Part 1. American Journal of Physical Medicine and Rehabilitation. 2005 June

2.     Barr KP, Griggs M, Cadby T. Lumbar Stabilization A Review of Core Concepts and Current Literature Part II. American Journal of Physical Medicine and Rehabilitation. 2005 June

3.     Gomes-Neto M. Lopes JM, Canceicao CS< Araujo A, Brasileiro A, Sousa C, Carvalho VO, Arcanjo FL. Stabilization exercise compared to general exercise or manual therapy for the management of low back pain: A Systematic review and meta analysis. Journal of Physical Therapy and Sports. 2017 Jan 23; 126-142

4.     Hicks GE, Elvira JL, Delitto A, McGill SM. Preliminary development of a clinical prediction rule for determining which patients with low back pain will response to a stabilization exercise program. Arch Phys Med and Rehab, 2005. Sep: 86(9)

5. . HodgesP,CresswellAG,DaggfeldtK,ThorstenssonA. Preparatory trunk motion accompanies rapid upper limb movement. Experimental Brain Research. 1999; 124. 

6. Hungerford B, Gilleard W, Hodges P, Evidence of altered lumbopelvic muscle recruitment in the presence of sacroiliac joint pain. Spine. 2003;28:1593-1600.

7. McGill SM, Karpowicz A. Exercises for spine stabilization: motion/motor patterns, stability progressions, and clinical technique. Arch Physical Med Rehabil. 2009 Jan;90(1):118-26. doi: 10.1016/j.apmr.2008.06.026.







Running and Low Back Pain- Risk Factors

Photographer: Parker Mauk&nbsp;

Photographer: Parker Mauk 

For runners, low back pain is a common problem. According to Concong et al, 13.6% of recreational runners in the southern United States report experiencing back pain and about 85-90 % of the general population have experienced low back pain at some point in their life.

I personally experienced a very bad bout of sharp back pain at mile 22 of my 2015 marathon, and in that instant I thought "my body is tired, my core muscles are not holding me up." We all have to keep in mind that running requires a lot of strength in order to tolerate immense repetitive stress. Our spine and legs have to work really hard to propel us forward not to mention that our backs alone have to tolerate weight 3x that of our own for miles! Therefore, it is clearer to see how back pain can develop if our bodies are not conditioned for this immense stress.

Risk Factors for Low Back Pain:

There have been many studies that have looked at some traits that individuals with low back pain exhibit. There have not been many studies that have specifically analyzed low back pain in runners. However, despite the lack of research on runners, when we look at the demands of running it can be suggested that these general deficits can be far more harmful to runners.  

On a lighter note, there have been studies that suggest that experienced or elite runners tends to experience less back pain. Which makes sense, these athletes have been conditioned for years!  So, it make some sense as to why many beginners may be at risk for developing some low back pain vs. experienced runners. 

Listed below are the top attributes that researchers have found in individuals who experience low back pain.

1.     Decreased lumbar extensor muscle strength and endurance


There have been a few studies that have found low back pain subjects demonstrate lower values of lumbar extension (low back muscle) strength compared to the non-low back pain group, specifically in the lumbar multifidus.

Paraspinals: group of muscles that run along the spine- from the neck down to the pelvis&nbsp;

Paraspinals: group of muscles that run along the spine- from the neck down to the pelvis 

The multifidi muscles are of the small yet powerful back muscles. They are a series of strappy muscles that originate at the spine and attach at each vertebral segment and some attach to the sacrum, and pelvis. When one side works these muscles helps rotate the spine and when both sides work these muscles extend the spine.   When we run these muscles do play in role in helping rotate and counterrotate our trunks as we swing our arms and legs. Therefore, if these little abundant muscles are weak, our paraspinals will overwork. 

It would be fair to also state that in 2006 study Renkawits et al found that both low back pain and non low back pain subjects demonstrates okay low back strength, however subjects with low back pain demonstrates  neuromuscular imbalance or in other words poor coordination of the back and core muscles (6). Which means, these low back pain patients had some strength but had difficulty using them at the appropriate times. In our instance, a runner may have a hard time engaging their core when they move/run. 

2.     Delayed activation of the transversus abdominis-

There have been many studies that look at core strength and its correlation to back pain. Our core muscles primary function it to maintain spinal stability (aluko), and researchers have found that one of the major caused in general low back pain, especially chronic low back pain has been the significant decrease in core strength (wen-dien)- specifically the transversus abdominis.  


The transversus abdominis is the corset of the spine and this muscle has 4 points of origin: the inner surfaces of the 7th to 12th ribs, iliac crest, thoracolumbar fascia, and the inguinal ligament. It inserts at the line alba ( center of the abs) and it works with the back muscles to stabilize the spine via intra abdominal pressure. This corset muscle  helps rotate the the trunk to the same side, and when both sides work they help depress the ribs and create tension in the abdominal area.  Poor poor muscle may also have a correlation to poor diaphragmatic breathing, which in turn causes excessive chest breathing which can also contribute to back pain. ( I can go into whole different topic which this so I will save it for a future post). 

As mention before this is one of the core muscle that represent weak in patient who exhibit back pain, especially with a side plank (3).  In 4 studies researchers took their low back pain subjects through a 6 week core strengthening regimen and after the strengthening program their low back pain subjects reported less pain and higher functional outcomes. 

3.     Weak glute maximus-


Our legs and spine both attach to our pelvises. Therefore, the role of the pelvis to stabilize both the trunk and lower extremities is very important. In a study conducted by Adams, researchers found that in subjects with low back pain the lumbo-pelvic muscles did not stabilize the spine as well as in individuals with no back pain. (1)

The major functions of the gluteus maximus during running are to decelerate the swing leg as we reach out with our foot and the glutes help power and extend the thigh back to. push off the ground. So if there is a power discrepancy in these hip muscles, something else was to take over, and that can be via the hamstrings and low back muscles.  A weak gluteus maximus and medius will also allow the knee to drop inward and cause the opposite hip to drop and therefore strain the low back.


4.     Stiffness of hip flexors

psoas stiffness.jpg

Lastly, another risk factor for back pain in runners can be tight hip flexors, which are the quads and psoas. Why may that be a risk factor, well both muscles attach at the hip and one of them goes as far as to attach to the lumbar spine. Therefore, if the muscles are stiff, you will be limited in hip extension during your push off during running gait and that will provoke excessive lumbar extension, which in turn causes more compressive stress at the back.


There was a study that looked at elite athletes and found that hip stiffness doesn’t correlate to back pain in athletes which is always good to keep in mind (5). I would go as far to say that stiffness itself may not be the sole cause to back pain, but more so that stiff hips actually inhibit the glutes for working as well as they should therefore lead to lumbar compensation. So, if you are stiff, I then would ask, how weak are your glutes. However, if hip flexor stiffness if pretty severe this for sure can provoke low back pain.


If you are a runner and are experiencing some sort of back pain, and do not work in any of these areas, it may be possible that you may demo some of these deficits.

Make sure to visit your local physical therapist for a more detailed assessment. Take care of it now before your symptoms get worse and affect performance.

I will be posting Part II: Training and Strengthening for Low Back Pain next. Stay tuned.




  Your team-mate, 







1.     Adams MA. Biomechanics of back pain.

        Acupunct Med. 2004 Dec; 22(4):178-88.

2.     Aluka A, DeSouza L, Peacock J. “The effect of core stability exercises on variations in acceleration of trunk movement, pain, and disability during an episode of acute nonspecific low back pain: a pilot clinical trial.”Journal of Manipulative Physiol. Therapy 2013 Oct;36(8):497-504.e1-3. doi: 10.1016/j.jmpt.2012.12.012. Epub 2013 Aug 12.

3.     Evans K,  Refshauge K, Adams R.,  Aliprandi L, “Predictors of low back pain in young elite golfers: a preliminary study,” Physical Therapy in Sport, vol. 6, no. 3, pp. 122–130, 2005

4.     Kujala U.M,  Taimela S, Oksanen A,  Salminen J.J, “Lumbar mobility and low back pain during adolescence. A longitudinal three-year follow-up study in athletes and controls,” American Journal of Sports Medicine, vol. 25, no. 3, pp. 363–368, 1997. 

5.     Nadler S.F,  Wu K.D ,  Galski  T,  Feinberg JH.  “Low back pain in college athletes. A prospective study correlating lower extremity overuse or acquired ligamentous laxity with low back pain,” Spine, vol. 23, no. 7, pp. 828–833, 1998

6.     Renkawitz T, Boluki B,  Grifka J, “The association of low back pain, neuromuscular imbalance, and trunk extension strength in athletes,” Spine Journal, vol. 6, no. 6, pp. 673–683, 2006.

7. Vahideh M, Memari AH, ShayesterhFar M, Kordi R Low Back Pain in Athletes Is Associated with General and Sport Specific Risk Factors: A Comprehensive Review of Longitudinal Studies Rehabilitation Research and Practice, 2015 (2015), Article ID 850184, 10 pages

HAMSTRING STRAINS: Risk Factors & Healing

Hamstring strains are a common lower extremity injury and it involves a strain or tear of 1 or 3 of the hamstring muscles or tendons.  The hamstring is made up of three muscles. The semitendinosus, the semimembranosus, and the biceps femoris muscle. They originate on the sit bones, otherwise known as the ischial tuberosities and run down the back of the leg, cross the knee and attach to the inner and outer part of the lower aspect of the knee.

Hamstring strains commonly happen when there is an excessive force placed across the muscle, typically seen with sprinting, sudden start/stopping motions, jumping, hurdling, and heavy lifting. During running a strain occurs during the eccentric contraction of the muscle, or when the hamstring elongates during the late swing phase (phase when you are swinging your leg forward and the knee straightens and reach out with the foot up to right before the foot touches the ground) (1-7).

Unfortunately,  there is a high injury reoccurrence rate that averages 31% over a sport season with the highest likelihood within the first 2 weeks of return to sport (3).

Hamstring strains are categorized as Grade I, II, and III strains.

Grade I : mild strain injury with minimum tear of the musculotendinous unit and minor loss of stress

Grade II: moderate strain injury with partial tear of the musculotendinous unit and significant loss of stress which results in significant functional limitation.

Grade III: severe strain injury with a complete rupture of the musculotendinous unit and is associated with severe functional disability (5).

In running the most common grade of injury are grades I and II.

Hamstring Strain Risk Factors:

Understanding the risk factors for hamstring injuries is really important in developing training programs in order to tackle these deficits.  There has been an abundant of literate to support the finding of these traits largely contributing to hamstring strains.

1.     Hamstring stiffness- With any muscle there has to be balance in length and strength. When an overused muscle also presents short and tight it cannot generate maximal force. Therefore, when large amounts of work are required, the muscle is essentially forced to contract even more causing injury. Heiderscheitexplains that after a strain hamstring length is really limited, normal flexibility of the hamstring should allow the leg to flex forward 80 deg with the knee straight (2).

2.     Hamstring strength and endurance deficits: In a study conducted by Orchard et al, they found that 30 players with hamstring injuries demonstrated significant lower hamstring strength than that non-injured counterparts.

Researchers also found that strains would occur during late portions of practices and competitions. This means that poor muscle endurance led to excessive fatigue, poor energy absorption, and decreased work output leading to injury (3).  

3.     Poor warming up prior to a work out or competition- increasing muscle temperature increase the muscle length. Physiological tests of muscles and tendons have shown that tissues that were “preconditioned” (stretching prior to testing force to failure) tolerated greater amount of stress before tissue deformity/tearing to the tissues that were not stretched prior. (4)

Signs and Symptoms You Strained Your Hamstring:

Screen Shot 2017-08-22 at 1.21.42 PM.png



Recent proposed rehabilitation guidelines are divided into 3 phases. (5,2)

Phase I: 1-7 DAYS

·      The focus after a strain is to control inflammation, swelling, and bruising. ( P.O.L.I.C.E) 

  • Protection

  • Optimal Loading

  • Ice

  • Compression

  • Elevation

Pigeon Pose Glute Squeeze

Pigeon Pose Glute Squeeze

·      Excessive stretching should be AVOIDED, but very gentle pain free range of motion is encouraged. Pain free single leg balance exercise, short stride stepping drills, isometric glute exercises are good exercises to carry out during the acute phase of a strain. Avoid resistance training of the hamstring muscle. Usually if there is a movement coordination discrepancy, such as an over dominant hamstring vs. increase glut activation you may  begin working on coordination here. 

 - Examples of coordination exercises: prone glute contractions, pigeon pose glute squeezes with knee extensions. 

·      In order to move on to phase 2, you should: be able to walk normally without pain, be able to jog very slow without pain, and be able to hold and isometric hamstring curl to 50-70% of submaximal strength without pain.



·      Return to full range of motion is a goal, and a gradual increase of exercises of:

  • BALANCE: Y- balance, unstable surface 
  • AGILITY DRILLS: ladder drills 

·      Begin gentle eccentric (lengthening) hamstring strengthening not concentric (shortening). You should be able to perform a bridge walk out in preparation to the next phase of return to sport.

·      In order to move onto phase III you must be able to: demonstrate full strength without pain, be able to jog forwards and backwards at 50% of your maximal speed without pain.

Phase III: 1-6 WEEKS // can last up to 6 month for complete ruptures. 

·      Hamstring flexibility should be back to 100% normal.

·      Progress eccentric and concentric hamstring strengthening with no pain.

  • Example: ( See picture bar below):
    • Bridges
    • single leg bridges
    • Single leg Russian deadlifts without and with weight,
    • walking lunges, walking lunges with rotations.
  •  Sprinters will begin quick takes off and breaks, runners will begin leg turn over exercises, farklegs, short distance bursts ONLY when you have been able to carry out all exercises WITHOUT PAIN. 



Grade II and III hamstring strains will take time to heal!  Patience is key and being smart about strengthening will be far more beneficial in the long run. Doing things the right way without rushing will only limit the chances of another reoccurring strain to occur. 




- Jessica Mena PT, DPT, CSCS










1      Erickson L.N, Sherry M.A. Rehabilitation and Return to Sports After Hamstring Strain Injury. Journal of Sport and Health Science.  2017.

2      Heiderscheit B.C, Sherry M.A, Silder A, Chumanov E.S, Thelen D.G.  Hamstring Strain Injuries: Recommendations for Diagnosis, Rehabilitaton, and Injury Prevention. Journal of Orthopaedic and Sports Physical Therapy. 2010 40: 2

3      Lui H, Garett W.E, Moorman C.T., Bing Y. Injury Rate, Mechanism, and Risk Factors of Hamstring Strain Injuries in Sports: A Review of the Literature. Journal of Sport and Health Science. 2012 V: 1:2

4      Mair S.D, Seaber A.V,. Glisson R.R, Garrett W.E. The Role of Fatigue in Susceptibility to Acute Muscle Strain Injury. American Journal of Sports Medicine. 1996 pp. 137-143

5    Petersen J, Holmich P. Evidence Based Prevention of Hamstring Injuries In Sport. British Journbal of Sports Medicine  2005;39:319e23.

6      Safran M.R.,   Garrett W.E.J. ,  Seaber  , . Glisson  , .Ribbeck B.M.. The role of warmup in muscular injury prevention Am J Sports Med, 16 (1988), pp. 123-129

7      Yu B., Kiu H, Garett W.E. Mechanism of Hamstring Muscle Strain Injury In Sprinting. Journal of Sport and Health Science.  2017 Vol 6: 2  pg: 130-132

Achilles Tendonitis


If you are reading this, it may be very possible that you or someone you know may be suffering from achilles pain.  Achilles tendonitis is an overuse condition most often seen in 15-18% of recreational runners (males more than females) between the ages of 35-45 (11). For runners an injury like Achilles tendonitis can force them out of training and competition. However, do not fret because you are not alone and there are ways to manage this. 



The Achilles tendon is the largest and strongest tendon in the body.  It's what connects the gastroc and soleus muscles (calf) to the foot, both the muscle and the tendon form a muscle-tendon unit- and this muscle tendon unit acts like a spring. It stretches and shortens in order to generate force to push us off the ground. So in basic terms, this tendon GETS WORKED when we run, spring, jump.  Lai et al. found that the work of the muscle-tendon-unit of the calf increased from 53%-62% to 74%-75% when subjects transition from jogging to sprinting. Therefore, imagine the stress placed on this tissue when running at race pace for an extended period of time.

In most cases the tendon is able to tolerate this stress, but somewhere down the line some intrinsic and extrinsic factors become overbearing and end up irritating the tendon.

What is Achilles tendonitis?


Achilles tendonitis is essentially the irritation and inflammation of the tendon. It can develop anywhere along the tendon- most commonly at the site of insertion (heel) or right in the middle of the tendon- about 2-6 cm away from the insertion site. At first the pain experienced is felt before and after activity. As the mechanical stress continues to plague the tendon, the pain progresses to being felt during activity as well.  Individuals will also report pain/tenderness when you touch the tendon. The tendon will also become thicker - as the repetitive mechanical stress leads to inflammation of the tissue and leads to fibrosis (thickening). 

What causes Achilles Tendonitis?

If you have been running for a long time and develop pain “out of nowhere”  it usually begins to develop from training errors. Training errors include sudden increase in mileage, increase in intensity, increase in hill training, returning too fast from an extensive break, or a combination of these things. However aside from some training errors – there will also be an influence from intrinsic risk factors you may present with.

Intrinsic Risk Factors:

1.     Limited Ankle Mobility- Dorsiflexion

·      There have been a few studies that demonstrated that individuals with  limited ankle mobility (5), as well as individuals with EXCESSIVE ankle dorsiflexion were both predictors for developing Achilles tendinopathy. (2,10)

·      The individuals that exhibited excessive ankle motion ALSO demonstrates weak plantarflexion (gastroc) power  (push off power), so being BOTH too flexibile and not strong enough may lead to  poor foot and ankle mechanics and therefore place stressed on the achilles tendon. ( 10)

2.     Too much or too little subtalar (midfoot) mobility

·      Researcher Kaufman found that individuals that pronate TOO much or presented with a rigid midfoot  demonstrated an increased risk for developing Achilles tendinopathy (6).

·      When you do not pronate at all, there is less shock absorption throughout the whole foot- leading to stress of all the structures of the foot and ankle.


.     When talking about excessive midfoot mobility / excessive pronation it is due to either muscular power deficits of the posterior tibialis or anatomical make up of the foot (pes planus/ flat foot). You may be asking how pronation can provoke achilles tendinitis, so think of it this way: the whole foot should function as one unit. Therefore if the the mid foot drops when you land it will pull the heel with it. This pull of the heel  (we call it calcaneal eversion) changes the pull of the tendon- creating an increase stress. ( see picture above) 

3.     Weak Gastroc (Calf) 

.     As mentioned earlier, ankle stiffness/excessive mobility in conjunction with weak plantar flexion strength has been linked to increase risk for developing achilles tendonitis. 

.     2006 study found that strength deficits of res that 50.0 N-m (36.87ft-lb : meaning 36 lb of energy/work per displacement of one foot) of the gastroc and soleus where significant predictors or an achilles tendon overuse injury (11). In another study researchers found a  4Nm difference in calf strength between runners with achilles tendonitis and those without (12).  So if you can't push off the ground there is more stretch than recoil, so you are just stretching and stretching that tendon. 

.     Usually individuals with weak calves will have to change the way the push off the ground, and that may be by either rolling off the inside of their big toe ( turning feet out). Just like anything else, excessive faulty movement will eventually lead to tissue irritation. 

 How to Help Yourself

What research says:

1.    Eccentrics

·      There has ben a good amount of evidence to strongly suggest the benefits of eccentric exercises. (1,5,8, 11, 12, 13,14)

·      In most of the research the eccentric exercise program lasted from 6-12 weeks- there was no specifics in bouts or reps but in this case I usually recommend started out lighter and work your way up. If you are running, your are loading and pushing for THOUSANDS of steps, so just doing 5-10 reps is not enough! Should start at 45 reps and then progress the exercises to actual heel raises.

Eccentric Heel Raises: 

PhysioU - Eccentric Heel Raises&nbsp;

PhysioU - Eccentric Heel Raises 

(1) Stand on a step with both heel hanging of the edge, holding onto the banister- push yourself up with the non-painful foot

(2) Then shift your weight to the affected side- keep heel nice and high and slowly lower down. 

(3) Sets 3x15 1-2 times per day 

(4) Keep pain moderate- if no pain at all - increase the weight by holding onto dumbness, and if the pain is too high ( > 5/10 pain) decrease the weight or repetitions.- (yes expect pain for average 4/10 pain for a few weeks- about 10-12 weeks)

2.    Stretching

·      Research has level II type of evidence of the benefits of stretching compared to Level I evidence to eccentric exercises.

·      There isn’t enough research to 100% support its magical benefits to Achilles tendinopathy, but it works for a lot of people- so it is something to try – especially more so for those who truly demonstrate limited ankle mobility. 

gastroc stretch.JPG

.    Along with stretching the gastroc- what also tends to help is the use of a heel lift- the concept is that the Achilles tendon needs more slack, therefore with a heel lift you are providing just that. 12-15mm heel lifts are recommended.

Standing Gastroc Stretch

(1) Stand in front of wall, with the involved foot back.

(2) Make sure both feet are facing forward.

(3) Keep the back leg/knee straight and lean forward until a stretch is felt in the calf. 

(4) Hold for 30 seconds- this can be multiple times per day. 

3.    Massage of the gastroc and soleus

·      This would occur in CONJUNCTION to stretching.  Look at this an attempt to release any muscle tension which would be followed with a stretch

·      Research shows that soft tissue mobilization of the calf muscles reduced pain and improved ankle mobility in patients with Achilles tendinopathy.

gastro foam roll.JPG

Foam Roll: Gastroc

(1) Sit on the ground, place involved side on top of the roller, and then place the uninvolved leg onto to add pressure 

(2) Lift your hips off the ground and slowly roll the calf up and down the foam roller

(3) Try to relax the muscle- it will be very uncomfortable- try going for bouts of 20-30 seconds for 3 rounds.  



Now as a clinician, usually foot/ankle/knee/hip mechanics all play in role in provoking injury.

I suggest to those who suffer from re-occuring and chronic Achilles pain to consult with a physical therapist, get a thorough evaluation with running gait analyzed .

Little movement impairments, muscle imbalance put together may be the perfect concoction for your injury.




Your Fellow Team-mate









1.     Carcia CR, Martin RL, Houck J, Wukich DK; Achilles pain, stiffness, and muscle power, an deficits: achilles tendinitis. Orthopaedic Section of the American Physical Therapy Association. J Orthop Sports Phys Ther. 2010 Sep;40(9):A1-26. doi: 10.2519/jospt.2010.0305. Review. No abstract available. 

2.     Chimenti RL, Flemister SA, Tome J, McMahon JM, Houck JR. Patients with Insertional Achilles Tendinopathy Exhibit Differences in Ankle Biomechanics as Opposed to Strength and Range of Motion.  Journal of Orthopaedic & Sports Physical Therapy, 2016. 46;12 p 1051-1060

3.     Christenson RE. Effectiveness of specific soft tissue mobilizations for the management of Achilles tendinosis: single case study—experimental design. Man Ther. 2007;12:63-71. math.2006.02.012

4.     Johansson C. Injuries in elite orienteers. Am J Sports Med.1986;14:410-415.

5.     Jonsson P, Alfredson H, Sunding K, Fahlström M, Cook J.  New regimen for eccentric calf-muscle training in patients with chronic insertional Achilles tendinopathy: results of a pilot study. Br J Sports Med.  2008; 42: 746– 749.

6.     Kaufman KR, Brodine SK, Shaffer RA, Johnson CW, Cullison TR. The effect of foot structure and range of motion on musculoskeletal overuse injuries. Am J Sports Med. 1999;27:585-593.

8.     Kedia M, Williams M, Jain L, et al.  The effects of conventional physical therapy and eccentric strengthening for insertional Achilles tendinopathy. Int J Sports Phys Ther.  2014; 9: 488– 497

9.     Kujala UM, Sarna S, Kaprio J. Cumulative incidence of achilles tendon rupture and tendinopathy in male former elite athletes. Clin J Sport Med. 2005;15:133-135.

10.     Lai A, Schache AG, Lin YC, Pandy MG.  Tendon elastic strain energy in the human ankle plantar-flexors and its role with increased running speed. J Exp Biol.  2014; 217: 3159– 3168

11.     Mahieu NN, Witvrouw E, Stevens V, Van Tiggelen D, Roget P.  Intrinsic risk factors for the development of Achilles tendon overuse injury: a prospective study. Am J Sports Med.  2006; 34: 226– 235.

12. McCrory JL, Martin DF, Lowery RB, et al. Etiologic factors associated with Achilles tendinitis in runners. Med Sci Sports Exerc. 1999;31:1374-1381. 

13. Alfredson H, Pietila T, Jonsson P, Lorentzon R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med. 1998;26:360-366. 

14. de Jonge S, de Vos RJ, Van Schie HT, Verhaar JA, Weir A, Tol JL. One- year follow-up of a randomised controlled trial on added splinting to eccentric exercises in chronic midportion Achilles tendinopathy. Br J Sports Med. 44:673-677.

The Scoop on Compression Socks

Photo credit: Martins Zemlickis&nbsp;

Photo credit: Martins Zemlickis 

Compression garments are now of the most popular items being used by various athletes especially runners.   Before this influx of the compression sock phenomenon these garments were used in the medical field to help patients with circulatory problems. The compression stocking would help individuals with venous insufficiency to reduce blood pooling at the feet and ankles. 

Now companies advertise compression socks as a helpful tool for aiding :

  • Recovery times via the increase in blood flow return
  • Reducing lactate concentration during and posts running
  •  Decreasing muscle stress from excessive pounding
  • Help reduce shin splints

Before I jumped into researching for data, I decided to give these socks a try. I worse 20mmHg compression socks that went up the whole lower leg. I wore then for 4-5 hours after 2 long runs, and yes they did actually feel good. However, I cannot say with 100% certainty that they did anything extravagant. I was still sore as heck the next day. After my little experiment was over, I went on the hunt for what the research community had to say about these garments.

 What are compression socks?

Compression socks or sleeves are worn just like a sock. The only difference is that the sock compresses the leg and foot and a sleeve compresses just the calf. The idea is that the compression will help with optimizing blood circulation back up the leg and decrease the amount of blood pooling at the feet and ankles.  The compression varies from 15mmHg up to 20-30mmHg. They come in all shorts of colors and now there are a few brands that manufacture these. 

As I stated earlier, compression stockings have been around for a long time, and medically are used to manage patients who suffer from excessive swelling due to lymphedema, venous insufficiency, spider veins, phlebitis, and deep vein thrombosis. 

Do they work ?

I have been searching and searching for peer reviewed articles on the topic. I have come across a few running blogs that claim research supports it without referring to the articles or author. On my quest to find reliable data,  I did not come across any recent peer reviewed articles that definitively conclude compression sleeves/socks serving the purpose they are marketed for. 

There was one study by Armstrong et al (2015) were researched found that after marathon, runner who wore compression garments 48 hours after running a marathon, and 2 weeks later was tested on treadmill to run until exhaustion, and the subjects that wore compression sleeves improved their time to exhaustion by 2.6% compared to the control group. A 2.6% improvement by marathon runner ended up being 56 seconds, which to me is not statistically significant. The next question would be, were these runner recreational, competitive/elite, and how would that screw the outcomes.

In another study by Kerherve et al 2017, the researchers found that athletes who wore a compression socks found no change in delated onset muscle soreness compared to the control group, but found a decrease in Achilles tendon pain. The researches stated that the decrease in Achilles pain may have stemmed from minor biomechanical changes observed at the foot and ankle during loading in the subjects who wore the compression socks. I even went as far to research effects of compression garments specifically for medial tibial stress syndrome (shin splints) and still found articles that concluded NO functional outcome improvements with compression socks (6). 

Majority impression from research community: COMPRESSION SOCKS DO NOT AID IN PHYSIOLOGICAL   optimization for healing and performance. (1,3,4,5,6,7)

However, I have read and heard from many runners that they feel that these items have made a difference for them. To those people I say, AWESOME, I believe you, and continue doing what works for you. 

BUT I will end this post with this, if you are solely relying on compression sleeves, even generic braces, tape, topical ointments to help with pain, don't. Pursue a health provided like a physical therapist to help find and address the primary problem, don't just cover up the pain. 

You should not be training or competing with pain, pain is an alarm that lets you know something you are doing is not optimal. 



Your fellow runner

Jessica Mena PT, DPT, CSCS 







1. Areces F, Salinera JJ, Abian-Vicen J, Gozales-Millan C, Ruiz-Vicente D, Lara B, Lledo M, Coso   J.  The Use of Compression Stocking During a Marathon Competitive to Reduce Exercise-Induced Muscle Damage: AreThey Really Useful? Journal of Orthopaedic and Sports Physical Therapy. 2015 45(6)p 46

2. Armstrong SA, Till ES, Maloney SR, Harris GA. Compression Socks and Functional Recovery Following Marathon Running: A Randomized Controlled Trial. Journal of Strength & Conditioning Research. 2015 29 (2) p.528-33

3. Goto K, Mizuno S, Mori A. Efficact of Wearing Compression Garments During Post – Exercise periods after 2 Repeated Bouts of Strenuous Exercise: A Randomized Crossover Design in Healthy Active Males. Journal of Sports Medicine 2017 3 (25) DOI 10.116/s40798-017-0092-1

4. Kerherve HA, Samozino P, Descombe F, Pinay M, Millet G, Pasquilini M, Rupp T. Calf Compression Sleeves Change Biomechanics but Not Performance and Physiological Reponses in Trail Running.  Frontiers in Physiology . 2017 April.

5. Mizuno S, Todoko F, Yamada E, Goto K. Wearing Lower-body Compression Garment with Medium Pressure Impaired Exercise-Induced Performance Decrement During Prolonged Running. PLOS ONE. 2017 12(5)

6. Moen MH, Holtslag L, Bakker E, Barten C, Weir A, Tol JL, Backx F. The Treatment of Medial Stress Syndrome in Athletes: A randomized clinical trial. Sports Med Arthrosc Rehabil Ther Techono. 2012 4 (12)

7. Treseler C, Bixby W, Nepocatych S. The Effect of Compression Stocking on Physiological and Psychological Responses after 5-km Performance in Recreationally Active Females. Journal of Strength & Conditioning Research. 2016 30(7) p. 1989-91


Does Running Cause Knee Arthritis- Review of Articles

Photo credit: NEW BASIN BLUES&nbsp;

Photo credit: NEW BASIN BLUES 

I have been a long distance runner for about 16 years now and as I get order I am experiencing less aches and pains than I did in my younger years, which is contrary to what many may expect.  Therefore, I wanted to investigate if long term distance running could actually increase the rate of arthritis development at the knee joint. 

This article will shed some light on what research says on the matter and I hope you feel delightfully surprised.

What is Arthritis?

Arthritis is the inflammation of a joint, and there are actually many types of arthritis. The most common form is osteoarthritis.

Osteoarthritis (OA) is the degeneration of bone surfaces, in other words “wear and tear” of a joint. Usually the cartilage will wear away first, which means there will now be exposure of bone surfaces (decreased joint space). When the bones are exposed there will be bone on bone rubbing which leads to pain, grinding , swelling, buckling, and stiffness.

What causes Osteoarthritis?

There are many factors are contribute to the wear and tear of the joint. One of them is your age. I tell my clients to remember that all of our tissues expire, we just have a long expiration date. 

·      Individuals over the age of 50 tend to have or develop arthritis. Makes sense, 50 years of loading a joint will eventually cause some wearing out.

·      Being overweight increases the chance of developing OA. More load causes more stress, and eventually more wear and tear compared to someone who is not overweight. 

·      History of knee injury- such as ACL tears, severe meniscus injuries, meniscectomies (removal of meniscus) because the integrity of the knee was been altered , causing more instability and thus more stress and rubbing.

· Strenuous repetitive activities - now this list varies from article to article. Some list long distance running as a strenuous activity other do not. (2,4)

What does research say about running and knee osteoarthritis? 

As a researched I found articles dating back to 1986 researchers have no found a strong link between lifelong distance running and early development of OA. A study in 2008 looked at 45 long distances runners and 53 controls (non runners). The runners were the average age of 58 when the study started in 1984 and were followed through 2002. The goal of the study was to document difference in knee osteoarthritis over the course of the years in runners and non runners. Towards the end of the study the researchers took and analyzed radiographs in both groups and found that the runners did NOT demonstrate more OA development than the non- running group (3). 

A recent 2017 research report was published by the Journal of Orthopaedic and Sports Physical therapy that looked at the very question.  The purpose of this article was to do a meta- analysis  of articles evaluate whether there is an association between knee and hip OA with running.  They analyzed 25 articles and looked at the prevalence of OA in recreational runners, competitive runners (professional/elite) and sedentary individuals.

Alentorn-Geli et al found after analyzing 25 peer reviewed articles that in general running WAS NOT associated with knee OA. The literature demonstrated lower odds for Hip and knee OA in  recreational runners  compared to competitive runners and non-runners. Competitive runners did demonstrate a higher association to joint degeneration compared to recreational runners. Which the researchers explained that in competitive runners:  age, workload, and sex were clear factors to that likelihood of OA development (>50, female, olympic distance runners) (6).  Alentorn- Geli et al, also reported that in 2 studies, runners that had ran more the 15 years vs runners who had  ran less than 15 years demonstrated a higher association to knee OA to the overall population by 17.2%. 

Basically:  RUNNING IS NOT ASSOCIATED WITH DEVELOPMENT OF OSTEOARTHRITIS, and if you have been running for +15 years like myself expect some degeneration (not shocking). 

Some limitation to the studies however were that the actually running workload were not specified between competitive runners and recreational runners.  It would be interesting to see what workload of running is too much. 


With that being said:  KEEP ON RUNNING!











1. Alentor-Geli E, Samuelson K, Musahl V, Green C, Bhandari M, Karlsson J. The Association og Recreational and Competitive Running with Hip and Knee Osteoarthritis: A Systematic Review and Meta- Analysis. Journal of Sports and Orthaepedic Physical Therapy. 2017. 47:6  DOI:10.2519/jospt.2017.7137

2. Beckett J, Jin W, Schultz M, et al.  Excessive running induces cartilage degeneration in knee joints and alters gait of rats. J Orthop Res.  2012; 30: 1604– 1610.  

3. Chakravarty E, Hubert H, Lingala V, Zatarain E, Fries J. Long Distance Running and Knee Osteoarthritis. American Journal of Preventative Medicine. 2008 35:2

4.Felson DT, Zhang Y, Hannan MT, et al.  Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum.  1997; 40: 728– 733

5. Konradsen L, Hansen E, Sondergaard L. Long Distance Running and Osteoarthritis. The American Journal of Sports Medicine. 1990 18:4

6. Kujala UM, Kaprio J, Sarna S. Osteoarthritis of weight bearing joints of lower limbs in former elite male athletes. BMJ. 1994;308:231-234. 

Strong Hips


Running is one of the most popular sports in the world, with 30 million people running the United States alone (2), i mean  what’s not to love!  It is easily accessible, it can be done literally wherever, whenever, and you don’t need any equipment. However, as much as I love that millions of people embrace running as much as I do, this sport records a high incidence of lower extremity injuries, most commonly in the knee, foot, and hip (1). The biggest reason being: YOU HAVE TO BE STRONG IN ORDER TO RUN. Like Dr. Irene Davis PT, PhD, FACSM, FAPTA said in one of her running symposiums “You gave to be fit to run… you should not run to get fit.” She is 100% correct, too many weaknesses lead to acute and chronic pains, and injuries. 

            When looking at running gait there are periods of floating, in which you are landing and pushing off of ONE leg. That is significant because now you are demanding the leg to support and react to not only just your body weight but also vertical load forces. Lets put that into perspective, every time your foot touches the ground, there is a large jump in body body weight by 5x through the knee, and 10x through the ankle (4). Therefore each time your foot makes contact with the ground there is a great demand for your ankle stabilizers, knee stabilizers, and hip stabilizers to  help sustain you and then push you forward (1).  Running is NOT easy, that’s probably why we sometimes feel like collapsing (figuratively) during fast or long runs.  In order for a runner to run with a relatively low number of injuries there has to be proper absorption, adequate alignment down from the ankle all the way up to the hip and trunk. When there is an inadequate amount of stability and strength in these areas,  that is when you begin to see manifestations of pain and injuries.  Running mechanics also play a huge role, and a lot of inconsistencies in gait are sometimes rooted in deficits of strength, mobility, or stability. So lets start with the hips.


            The hips play a vital role in running, because hip extension is needed in order to get you from foot strike to take off. Therefore, strong glutes will be able to provide powerful hip extension through the stance phase of gait.  The glutes are compiled of the gluteus medius, gluteus maximus, and gluteus minimus.  The gluteus maximus mostly works with extension, so its helps drive your femur back, and the gluteus medius helps abduct or bring your leg out to the side. When both work in tangent these muscles help control your hip.  Some runners exhibit a hip drop when they run which is called “trendelenburg gait." When we see this it usually means that there is a weakness in the hip abductors/ gluten muscles. A hip drop contributes to increase loading on the outside of the knee, compression of joints in the spine, and increase activity in the back muscles (1).  

knee valgus.png
Dr. Matt Klein PT, DPT- competitive runner for Cal Coast Track Club&nbsp;

Dr. Matt Klein PT, DPT- competitive runner for Cal Coast Track Club 

In a study conducted my Smith et al , the researches found that women who demonstrate weakness in the hip abductors (gluteus medius) exhibited more side bending of the trunk and internal rotation of the knee (knee turning in) more so than the women with relatively strong hip abductors (4).  In another study by Davis et al, the researchers studied 20 female runners that exhibited excessive femoral internal rotation and adduction and put them in a 6 weeks glute strengthening program.  What they found was that there were improvements in the mechanics of a single leg squat, but not so much during running gait.  Yet in another study by Snyder et al, they found that strengthening the hip abductors did in fact reduce the amount of hip drop and knee adduction (knees coming in)  by 5% (5). So both of these articles are important because they tell us that strengthening is beneficial, however if we are not specific in changing mechanical flaws, then strengthening alone may not entirely solve the problem.  We will get into mechanics in a later blog,  however it is good to note that both strength, and mechanics go hand in hand. Nevertheless, sometimes its hard to change mechanics when you do not have sufficient strength.  So to all my runners out there training for short or long distances, you should dedicate some time to strengthening your glutes. 

And when it comes down to glute exercises some are better then others. Snyder et al, found in their study that the best exercise to get the whole glute to activate and strengthen were the forward lunge, bilateral and unilateral bridge, firehydrant, and the squat.  The well known clam tends to get mostly the superior fibers along with the sidelying hip abduction, sidestep with the band, and the step up.

 I have gathered some of the top 5 exercise with the studies I have mentioned above in mind. 

1. Double leg bridge- feet on a step ( for more hip extension) 3x15: For this exercise you don't need your feet elevated on any step if you have any neck or low back problems. As the picture shows, you are laying on your back.  You do want to be mindful of your abdominals as they should be slightly braced. The band is placed right above the knees, with the intension that you are pushing your knees out (abducting) in order to get the glute medius to fire better. The feet should be shoulder width apart. I have them slightly wider because I get the muscle to activate a little more. You may need to play with the width of the your feet.  As you bring your hips up, tighten your buttock together, and don't forget about tightening the core. 

2. Firehydrant with a band around the knees- 3x10 In a quadruped position, place the band right above the knees.  You want to be in neutral spine, meaning you do not want to let your back arch down or round up. As you are lifting the leg/knee, you want to extend the hip a little and think about kicking your leg back slightly and turning your knee up towards the ceiling. 

3. The MENA squat- Credit to Randal Glaser for this one.This is my favorite. It is a Single leg squat on steroids. You are going to place one foot up on the wall (heel has to stay on the wall through out), then hop out a little with the front leg, it is a wide stance. As you squat straight down make sure the knee does not travel over the toes and hold for a count of 3 and come right back up and squeeze the buttock of the lead leg.  Good luck with doing 10 without feeling the BUTT BURN!!!!!

4.  KB Goblet squat with band around knees- Hold a KB >10lb up high (goblet hold), think about squeezing the shoulder blades back as you hold the Kettle Bell (KB). Feet will be positioned wide, about shoulder width apart. You will squat down following the same rule of "no knees over toes". You will hold for 2 seconds and come right back up and squeeze your buttock together. Then repeat. If you are feeling good, you can place a band around the knees.  3x15

5. Single leg squat- 3 count down and up.   Stand in front of a box 12-18 inch box, decide what leg you will start off with first. Balance on the leg, and slowly squat down until your bottom taps the box, and then you will push yourself back up. The important part here, is making sure that your knees stays in line with you ankle and hip!!!!!  If you cannot do that, you may need to start with a higher box or with the use of a stick/dowel or TRX suspension.  3x12 each side


General strengthening is IMPORTANT for injury prevention.



The PT to the Runners, 





1. Byl N, Davis I, Heiderscheit B, Powers C. (2013) Research Symposium- The Science of Running.  Lecture retrieved from CPTA conference.

2. Kurihara D. Running Lecture (2015) PDF- Azusa Pacific University.

3. Selkowits DM, Beneck CM, Powers CM. Comparison of Electromyographic Activity of the Superior and Inferior Portions of the Gluteus Maximu muscle during common therapeutic Exercises. Journal of orthopedics Sports Physical Therapy. 2016; 46 (9) 794-799

4. Smith, JA. Popovich JM, Kulig K. The Influence of Hip Strength on Lower-Limb, Pelvbic, and Trunk Kinematics and Coordination Patters During Walking and Hopping in Healthy Women.  Journal of Orthopaedic & Sports Physical Therapy. 2014; 44 (7) 525-531

5. Snyder KR, Earl JE, O’Conner KM. Resistance Training in Accompanied by increase in Hip Strength and Changes in Lower Extremity Biomechanics During Running. Clinical Biomechanics. 2009; 24 (9) 26-34

6.  Willy RW, Davis IS. The Effect of Hip Strengthening Program on Mehcanics During Running and Single Leg Squat. Journal of Orthpaedic & Sports Phyical Therapy. 2014: 41 (9)  625-632

"Runners Knee" = Patellofemoral Pain Syndrome

2010 Regionals-&nbsp;Whittier College and Claremont

2010 Regionals- Whittier College and Claremont

 What runner has not experienced some sort of knee pain? If you have not, you are onto something good. Unfortunately, every year about 2.5 million runners will be diagnosed with Patellofemoral pain syndrome (PFP) (5).  PFP is also known in the streets as “runners knee” and unfortunately according to Powers 70%-90% of people suffering from PFP will have recurrent pain (3). So, what exactly is PFP? How does it develop? What are some symptoms of PFP? How can you prevent it? I am here to answer these questions.


What is Patellofemoral pain syndrome, and how does it develop?

Patellofemoral pain syndrome refers to pain in the knee and around the knee cap (patella) area. It tends to affect women more than men, and is very common in athletes especially runners. Up to now researchers have found this to be more of an overuse injury that develops from the patella tracking poorly over the knee joint.

PF joint.png

 It essentially develops from muscle imbalances of the lower quarter that cause faulty movement at the knee joint. The faulty movement causes excessive patellar friction /rubbing up against the femoral condyle and with prolonged stress ends up causing pain.

What are some specific contributing factors?

There has been a large interest in researching what exactly causing PFP, but for the most part most studies have found that the following factor tend to play a role in PFP (4):

·      Poor tracking of the patella

·      Excessive midfoot drop (pronation)- this will cause the lower leg (tibia) to rotate inwards causing the knee to dive in.

·      Lack of ankle mobility, especially into dorsiflexion – alter foot position causing the foot to externally rotate, and promote midfoot drop

·      Weakness of the hip stabilizers ( glutes ), which influence the position of the knee with the hip and foot, what we will most commonly see in the knee diving in too much.

·      Excessive quadriceps activity- causing too much compressive forces of the patella-femoral joint or VERY weak quadriceps that lead to poor knee stability.

Look at my last 2 post about mechanics to get more detailed examples of mechanical faults in running. **


What does it feel like when you have PFP?

A lot runners describe an achiness around the knee cap or behind in knee cap. Some will also report some grinding or creaking.

Runners will report pain with:

·      Going up/down stairs

·      Squatting

·      Increased activity /running

·      Standing after prolonged sitting

·      Kneeling

·      Hopping/jumping


How can you prevent it?

·      Cross train and work on strengthening your glutes and quads, in a study conducted by Khayambashi et al, the researchers found that there was a decrease in knee pain after just 6 weeks of following a glute strengthening program in females with PFP. (1,2,3) 

·      Dedicate time to maintaining muscle flexibility especially those of your quads, hip flexors, and calves

·      Be more aware of how you are moving! For example if you were to get up/down from a chair do your best to avoid the knees diving in. This pertains to all activities really : gym exercises (squatting, lunging, step ups), stairs, walking, sit to standing.


What to do if you think you may have it?

The root of the problem for each case may be slightly different.

Generally strength deficits and faulty movement tend to be the common impairments. But for those who think they may have PFP visit a physical therapist. Let someone take the time to access you and provide a catered plan of care especially if you have noticed that this has become a reoccurring problem. As therapists, our job is to be slightly nitpicky and assess movement, coordination, strength, and flexibility and assist you to returning to sport strong and ready! 


Train Smart

Stay Healthy

Run Happy

Jessica Mena DPT, PT, CSCS






References/ Reads: 

1. Fakuda, T., Rossetto F, Magalhaes E.,  Bryk F., Lucareli P., Carva N. Short Term Effects of Hip Abductors and Lateral Rotators Strengthening in Females with Patellofemoral Pain Syndrome: Randomized Controlled Clinical Trial.  Journal of Orthopaedic and Sports Physical Therapy. 40(11) Nov 2010.

2. Khayambashi K., Mohammadkhani Z, Ghaznavi K., Lyle M., Powers, C. The Effects of Isolated Hip Abductor and External Rotator Muscle Strengthening on Pain, Health Status, and Hip strength in Females with Patellofemoral Pain: A Randomized Controlled Trial.  Journal of Orthopaedic & Sports Physical Therapy, 2012 Volume:42 Issue:1 Pages:22–29 DOI:10.2519/jospt.2012.3704

3. Magahlaes E., Fakuda T., Sacramento S., Forgas A., Cohen M., Abdalia R. A Comparison of Hip Strength between Sedentary Females with and without Patellofemoral Pain Syndrome. Journal of Orthopaedic & Sports Physical Therapy, 2010 Volume:40 Issue:10 Pages:641–647 DOI:10.2519/jospt.2010.3120

4. Powers, C., Bolgla L A., Callaghan M.J., Collins A., Sheenan F.T. Patellofemoral Pain: Proximal, Distal, and Local Factors 2nd Internal Research Retreat.  Journals of Orthopaedic and Sports Physical Therapy. 2012 August 31-September 2.  Ghent, Belgium, doi:10.2519/jospt.2012.0301

5. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med. 2002;36:95-101

If The Shoe Fits

Birmingham HS Track: Brooks Launch

Birmingham HS Track: Brooks Launch

Thanks to the English, the first running shoes were developed about 200 years ago. Fast forward to modern day, and now the selection of running shoes available to runners are endless. The most common types of running shoes available are categorized into neutral, motion control, cushion, and minimalist shoes. The luxury of having many options is great, however for most people picking the correct shoe can be difficult.  More difficult if the runner is unsure as to what their deviations and weaknesses are comprised of.

The goals of this article is to provide information as to what recent research is saying about shoes and their role in injury prevention.


Now before we go into shoe specifics, I will say that working foot and ankle strength is essential! If you are running, you should WANT to have strong hips, ankles, and feet. When these supporting areas are strong enough then your risk for injury does decrease. However, if you are solely relying on shoes to help prevent aches and pains, the truth is, you will probably experience them.

In a study conducted by Knapik Et al, the researchers found no correlation between the reduction in running injuries and “sophisticated footwear design and shoe prescription.” (3) That is something you take with a grain of salt, but also something that should creep around in the back of your head.  Shoes are important, but you have to take into account the strength that you already have, your mechanics,  and the supplemental support needed from a shoe.

When it comes to picking the right shoe, most of us look at comfort, fit, and use.

In the last couple of years there has been a surge of interest in minimal shoes and barefoot running, and well as the heavily supportive rocker shoes like the HOKAs and Altras. Both types of shoes land on the very ends of the spectrum and are designed for very different runners. Rose, et al. looked at the effects of motion control  shoes and neutral shoes and found that, yes, there was a significant decrease in midfoot pronation during running in runner that wore motion control shoes vs. the neutral shoes. They described the improvement in foot positioning due to the higher and sturdier midsole design.  The searches also found a reduction in ITB pain in the runners that exhibited midfoot pronation and made a switch to motion control shoe, which is fantastic. However, then we go back to the question of, would it be possible to reach the same outcome with just strengthening of the hips and feet or even core?  I would answer that as probably YES, but it would take much more time to gain the same effect.

In a another study by Sobhani et al, they looked at running economy in a rocker shoe, minimalist shoe, and a standard shoe (neutral) and found that the runners demonstrated increase energy expenditure with the rocker Altra shoe compared to the standard and minimalist shoe (6). The outcome was believed to have developed due to the increase in shoe weight and change in mechanics specifically in reducing ankle range of motion. The people that actually may benefit from this type of shoe are runners who truly have deficits in dorsiflexion range of motion, or big toe extension deficits. The problem with a very cushioned and supportive shoe is that it does promote a rearfoot strike. Mechanics can actually play a great deal, and we will get into that in the next post next week.   

In terms of running with minimalist shoes, there has been a greater effort into researching the benefits or risks of these types of footwear.   David et al discuss that the more cushioned the shoes are, the more likely runners will change to a rear foot strike which alters the load on the lower extremity leading to higher incidence of injury (2).  They also state that 95% of non minimalist runners strike with the heel and only 1% with the forefoot. While on the other hand, most minimalist runners land with the forefoot.  To coincide, Chen et al found that when they transitioned a group of runners to running in a minimalist shoes over the course of a 6 month period, there was an increase in muscle volume of the foot intrinsics by 7-9%. There was also a change to from rear foot to forefoot striking, compared to no change in muscle volume or strike in the runners who continued to run in the traditional neutral shoe (1).  Similarly in another study conducted by Miller et al, the researcher  found that after a 12 week program of running in minimalist shoes (0 deg drop shoe) the runners demonstrated an increase in the foot intrinsics, stimulating the arch of the foot to become more springy AND stiffer (4). Both of these components  are needed for shock absorption and foot support.  The researchers ended their article with the hypothesis that a more supportive shoe doesn’t allow the foot to actually function properly and minimalist shoes force the foot to work harder, therefore creating an environment for strength development.  

Personally, the moment I started wearing more minimalist shoes, not necessarily a zero drop, more so around the 4-6 mm drop I have noticed a huge change in foot injuries. I have had 2 in the last 6 years. In college I suffered  2 stress fractures and countless sprains. I have changed a lot, mostly working on ankle stability and foot strength, so I can tolerate running in a minimalist shoe much better than someone who does not work on those component or transition slowly enough.

At the end of the day, you should know what works best for you. You take in information, make changes and make decisions accordingly. Not every runner runs the same, not every runner has the exact same issues, but it is good to take into account what research is coming out with. Facts are facts. Implement some good changes in order to improve your training and performance.






Check out Irene Davis talking to JetSetRehab Team  about treating the injured runner.

Irene Davis is the running rehab guru. She runs her practice out of the Spaulding Harvard National Running Center, and has published countless articles in regard to running, running biomechanics, and rehabilitation.  Check out this podcast. ENJOY!



1. Chen T, Sze, L.K., Davis, I.S.,  Cheung R. TH. Effects of training in minimalist shoes on the intrinsic and extrinsic foot muscle volume. Clinical Biomechanics 36 (2016) 8-13


2. Davis I.S., Rice, H>M., Wearing S.C. Why forefoot striking in minimalist shoes might positively change the course of running injuries.  Journal of Sports and Health Sciences 2017. 1-9


3. Knapik J.J., Trone D.W., Tchandja J.,  Jones B.H. Injury- Reduction Effectiveness of Prescribing Running Shoes on the Basis of Foot Arch Height: Summary of Military Investigations. Journal of Orthopaedic and Sports Physical Therapy. 2014 44:10, pgs 805-812


4. Miller E., Whitcome K., Lieberman D. E.,  Norton H.L.,  Dyer R.E.  The Effect of minimal shoes on arch structure and instrinsic foot muscle strength.  Journal of Sports and Health Sciences.  2014, 3; 74-85


5.Rose A, Birch I,  Kuisma R. Effect of motions control running shoe compared with neutral shoes on tibial rotation during running. Physiotherapy . 97 (2011) 250-255


6. Sobhan S, Bredeweg, S. Dekker R.,  Kluitenberg B., van den Heuvel E, Hijman J, Postema. K.  Rocker shoe, minimalist shoe, and standard running shoe: A comparison of running economy. Journal of Science and Medicine in Sport. 2014 , 312-316

Hello Posterior Tibialis

Most runners at one point or another have suffered from an ankle or foot injury.  Some injuries may have ranged from full blown tendinitis, a stress fracture, sprain, or just ambiguous soreness.  It is easy to overlook the feet, rather than pay a little more attention to them.

The foot itself is a rather complex structure. 26 bones, 33 joint, 6 main nerve branches, 19 muscles, and 107 ligaments make up the foot. Safe to say, there are a lot issues that help make up our feet and essentially allow to propel our heavy bodies just with walking. They should be strong and flexibility at the same time, and then one of those components is missing, people start getting into trouble. When we add running into the mix, it is clear to see how important foot and ankle stability, strength, and endurance are for our training and performance. In terms of strengthening the foot and ankle, it is better to first pay attention to the bigger ones which are crucial in helping maintain shape and also manage stress and flexibility of the foot.

 Lets recall that the most frequent running related injuries are medial tibial stress syndrome (shin splints), Achilles tendinopathy, plantar fasciitis, and patellar tendinitis (1).   When we take a look at the bigger picture in order to explain why these injuries develop , clinically therapists will usually find deficiencies in hip strength and ankle/foot strength. When looking at the ankle and foot, the weaknesses that are most commonly seen are in the posterior tibialis, and fibularis longus muscles. Weaknesses in these areas end up causing biomechanical alterations in the whole lower quarter during regular walking gait, and more so during running. Over time, if the weakness persists the repetitive strain will lead to injuries. 

The role of posterior tibialis muscle is to plantarflex (point foot down) and invert (point foot inwards)  it also helps to keep the midfoot (arch of the foot) from falling too far down towards the ground. The fibularis longs (or peroneus longus) is in charge of plantar flexing and everting (point the foot out) the foot.  Therefore is the posterior tibias for instance is not strong enough to carry out its role, it will cause excessive mid foot drop, which will pull your knee and hip inward. 

 In a study conducted in 2001 by Bennett et al, they found that in a group of 125 cross country runners, the ones who developed medial tibial stress syndromes (shin splints) were the ones who demonstrated increase midfoot pronation (1).  Well, what typically causes midfoot pronation? Sometimes the way you are structurally built influences foot position.  Individuals with naturally lower arches are more likely to exhibit excessive pronation and are 3x more likely to experience posterior tibialis tendinitis, compared to individuals with high arches (3).  But to keep it clean and simple, it is common to find a weakness of the posterior tibialis muscle in individuals that demonstrate excess mid foot pronation. Neville et al, also demonstrated that subjects with posterior tibial tendonitis had significantly lengthened tendon/muscle (it is hard to say which is truly lengthened) and increase midfoot pronation compared to the healthy group. The individuals with tendonitis demonstrated lower function, and mobility during gait especially during the loading phase and push off phase (terminal stance) overall.

In a runner, weakness of the posterior tibialis can really cause havoc. How can you expect to run30 + minute runs and repetitively stress the arch of your foot as well of the muscles without eventual consequences. 

Traditional foot strengthening exercises usually involve curling the toes, picking up marbles, curling towels or something of that sort.  Which is okay, but how does that directly translate over to running gait? It would be more ideal to practice the short foot position in weight bearing exercises, such as heel raises, single leg heel raises, squats, single leg squat, single leg balance, sidesteps instead.


Train smart, take care of your body, take care of your feet

Happy running, 

Jessica L. Mena PT, DPT, CSCS

Posterior tibialis exercise with a theraband: Some people do the pointing down of the foot and holding for a second and going for repetitions. I tested this the last few weeks with with prolonged 30 seconds holds and really found that much more effective. With a moderately difficulty resistance, point the foot and toes doing and inward - without moving the &nbsp; lower leg and knee- and hold for 30 sec, break for 10 sec and repeat x5 . &nbsp;This should be a warm up before a gym work out or run.&nbsp;

Posterior tibialis exercise with a theraband: Some people do the pointing down of the foot and holding for a second and going for repetitions. I tested this the last few weeks with with prolonged 30 seconds holds and really found that much more effective. With a moderately difficulty resistance, point the foot and toes doing and inward - without moving the   lower leg and knee- and hold for 30 sec, break for 10 sec and repeat x5 .  This should be a warm up before a gym work out or run. 

Short foot: When doing this technique/exercise you want to begin by understand that the goal is to apply only 3 points of contact from the foot into the ground. There is a point of contact under the base of the big toe, under the base of the small toe and the heel. From there, attempt to lift the mid foot up and off of the ground, by gently pressing down with your big toe  without scrunching your toes or lifting your heel. Once you get the hang of that concept and the ability to raise your arch, progress to maintaining the short foot with 

1. Seated Heel raises: you will raise onto the ball of your feet and over your big toe and return slowly

2. Standing short foot with Single leg balance , to make it harder single leg balance with reaching forward and back with the opposite leg. (use cones as targets) 

3. Double leg squat with short foot. 

This takes a lot of time and practice, be patient and remember that quality over quantity is what matters initially, you can progress quantity once you get the form down. 

Think about working on your short foot when your are waiting in line, brushing your teeth, showering, or working out at the gym. 

Image above is one of my self. The Bottom left image is my weight bearing right foot, and you can see that compared to right image of my weight bearing left foot, the inner aspect of my mid foot is different. In the left image my right mid foot drops compared to the picture of the right where you don't see that on my left foot. I was asymptomic for months until I started running 18 + miles, i ended up developing foot pain. &nbsp;Imagine all the strain my foot endured every step I took and landed like the picture on the right?&nbsp;

Image above is one of my self. The Bottom left image is my weight bearing right foot, and you can see that compared to right image of my weight bearing left foot, the inner aspect of my mid foot is different. In the left image my right mid foot drops compared to the picture of the right where you don't see that on my left foot. I was asymptomic for months until I started running 18 + miles, i ended up developing foot pain.  Imagine all the strain my foot endured every step I took and landed like the picture on the right? 

1. Bennett J.E., Reinking M.F., Pluemer B., Pentel A., Seaton M., Killian C. Factors Contributing to the Development of Medial Tibial Stress Syndrome in High School Runners. Journal of Sports Physical Therapy. 2001.  31 (9) 504-510

2. Chimenti, RC., Flemister, S.A., Tome, J., McManhon J.M., Houch J.R. Patients with Insertional Achilles Tendinopathy Exhibit Differences in Ankle Biomechanics as Opposed to Strength and Range of Motion.  Journal of Sports Physical Therapy, 2016. Vol 46:12 pg 1051- 1060

3. Neville, C., Flemister A., Tome J., Houck J. Comparison of Changes in Posterior Tibialis Muscle length between subjects With Posterior Tibial Tendon Dysfunction and Healthy Controls During Walking. Journal of Sports Physical Therapy. 2007 Vol 37:11.