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5 Pieces of Advice for New PT Grads Looking to Work with Injured Runners

11/13/2015

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Everyday, I receive an email or message from a recent physical therapy graduate, who is looking for guidance in terms of refining their approach to working with runners, or looking to establish themselves as a running rehab specialist. Although it takes time to master any craft, I thought it would be helpful to share a few pieces of advice/reminders to put you on the right path. By no means is this a comprehensive list, but rather, some simple suggestions that have helped me over the years. Lastly, it's critical to bear in mind that your ability as a runner has relatively little impact on your ability as a therapist, so never confuse the two.


READ ONE JOURNAL ARTICLE PER WEEK
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"Everyone is entitled to his own opinion, but not to his own facts." -Daniel Moynihan-
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Having spent considerable time in the research lab at the University of Delaware, in addition to working as a research assistant and PT at the Nicholas Institute of Sports Medicine & Athletic Trauma (NISMAT), I had no choice but to immerse myself in the literature. Dr. Malachy McHugh, who is the current Director of Research at NISMAT, used to always remind me that clinical decisions should be driven by evidence rather than belief. So, if you want to be taken seriously, it's important to speak in denominators.


CONNECT WITH A RUNNING COACH
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"A coach is someone who tells you what you don't want to hear, who has you see what you don't want to see, so you can be who you have always known you could be."
-Tom Landry-

There are some amazing coaches in the world of running. Chances are that there is even one in your town. Find out who they are and ask to train with their group if they are taking on new members. Otherwise, see if you can get them out for a coffee or a drink. Believe me, they could all use a good PT and will never turn down an opportunity to talk shop.


HANG OUT AT THE LOCAL TRACK

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 "You can observe a lot by just watching" 
-Yogi Berra-

One of the best ways to learn more about running is to simply spend time at the local track watching runners train and race. You will see runners of all shapes, sizes, ages, and abilities while getting immersed in the running culture. And please don't be shy! Introduce yourself and tell people what you do from a professional standpoint. Considering the high incidence of running related injuries (RRIs), chances are that you will make some friends ;-) 

SPEND TIME WITH STRONG PEOPLE
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"If there's one thing that runners should do beyond running, it's strength train." - Gregory Lehman

When looking at the available body of research, it's become readily apparent that strength training plays an invaluable role in safeguarding against injury while improving running economy. Although the vast majority of runners are concerned that they will only put on mass or risk injury, this is a myth. So find the strongest people and the most well respected strength coaches in your area and connect with them. Remember, "you don't earn strength, you learn strength."


INFUSE PAIN SCIENCE & MI 
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"Innovation is not about tricks, gimmicks, and products. It's about behavior change!"  -Al Smith-

The most brilliant clinicians I know possess an uncanny ability to weave pain science and motivational interviewing (MI) into their care. Irrespective of what approach or system you follow, it will be far more effective if you are able to help patients re-conceptualize their situation while facilitating positive behavioral change. That is where the true magic of our profession lies. So, if you are ever looking to take a con ed course, pick one related to pain science and/or MI. 
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Return to Running Rules of Thumb - Are You Ready?

11/3/2015

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I recently shared a simple return to running program for medical and fitness professionals to help injured runners return to consistent training. Before initiating such a program, however, a runner should meet certain prerequisites or milestones to ensure that it is appropriate to advance their activity level while avoiding a potential relapse in their condition. In the event a runner does not meet the items on this checklist, and prematurely attempts to return to training, they are playing with fire and will most likely prolong their recovery. So before transitioning a runner back to training, take the time to ensure that they meet the prerequisites outlined below. ​



​NO SIGNS OR SX OF INFLAMMATION
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PILLS & INJECTABLES OUT OF YOUR SYSTEM 
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​ABILITY TO FULLY WEIGHT BEAR THROUGH THE AFFECTED EXTREMITY 
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​ABILITY TO PROGRESS THE LEG OVER THE FOOT 
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​TOLERANCE OF OPEN CHAIN LOWER EXTREMITY EXERCISES


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​TOLERANCE OF CLOSED CHAIN LOWER EXTREMITY EXERCISES
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​GOOD FRONTAL PLANE CONTROL
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​TOLERANCE OF 45-60' OF FITNESS WALKING
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​TOLERANCE OF REPETITIVE SINGLE LEG HOPPING IN MULTIPLE DIRECTIONS
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Common Denominators of Running - Let's Agree on Something

6/10/2015

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As the debate rages on regarding strike pattern, shoes, and one universally best form to run, how about we first establish consensus regarding common denominators related to running. This past weekend I was fortunate enough to have my uncle, who is visiting Seattle and also happens to be a professional photographer, capture some footage of me running to highlight several key aspects of the running gait that we have to prepare injured runners for as we attempt to return them to daily training and beyond. Ive included three separate pictures to capture three distinct portions of the gait cycle which are as follows and listed from left to right: terminal stance, float phase, and midstance. As you look at these images, it's important to keep in mind that I'm running on level ground at 4:30 pace in the Brooks Launch (10mm heel to toe differential). Below, I've listed some key characteristics and takeaways related to the above images. I've also include footage from a few clips of me running on a treadmill to give you a more thorough perspective of the running gait to compliment the above images.

Terminal Stance
1. The runner has to progress through the forefoot and ideally the first ray which demands mobility at the first MTP.
2. The knee does not fully extend on the stance leg in the vast majority of cases.
3. Some hip extension is necessary on the stance leg though not nearly as much as some folks lead you to believe.
3. The trunk is erect and the head is held steady.
4. There is a good deal of shoulder extension that occurs on the contralateral side relative to the stance leg.
5. The pelvis and shoulders remain relatively square.
6. A moderate amount of hip flexion is necessary though definitely less than 90 degrees.

Float Phase
1. The brachium (upper arm) never breaks the plane of the torso despite sometimes giving the appearance of doing so. 
2. There is a distinct float phase that is inherent to the running gait. 
3. A small amount of torso rotation occurs during the running gait. 
4. The tibia of the left or more anterior lower extremity is positioned relatively vertical and the foot is positioned close to level with the ground.
5. Although it appears as if I may be overstriding, the foot winds up landing almost underneath my body by the time it contacts the ground (easier to see in the video below).
6. The trunk is erect and the held is held steady.

Midstance
1. The quadriceps act eccentrically during the stance phase.
2. The leg must progress over the foot thus demanding ankle dorsiflexion
3. There is minimal hip ADDuction that occurs during the stance phase.
4. There is minimal ipsilateral trunk lean towards the stance leg during this phase.
5. The trunk is erect and the head is held steady.
6. The knee of the non-stance leg flexes to ~120 degrees though in most recreational runners this value is ~90 degrees while with world class sprinters it can reach 135+


Based on this information, I thought it would be helpful to list my prerequisites to safely return injured runners to regular training and beyond.

1. No use of NSAIDs or narcotics
2. No signs/Sx of inflammation
3. Ability to fully wt bear through the affected region(s)
4. Adequate toe dexterity (flex-ext of the great toe and lesser toes, splaying, and adduction
5. Ability to balance in a wobble free manner for >30s such that there is no reliance on an arm nor trunk strategy.
6. @ least 35+ degrees of isolated extensions of the 1st MTP extension in a WB position at terminal stance.
7. Ability to progress the leg over the foot (~22 DF)
8. Tolerance to open and closed chain contractions of the lower extremities
9. Good frontal plane stability esp @ hip & trunk
10. Tolerance of fitness walking (3.5mph) in a defect free shoe
11. Tolerance of a progressive walk-run routine
12. Ability to hop in multiple directions on each leg

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3 Simple Reminders for Injured Runners

4/1/2015

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Every day I have the privilege to work with injured runners, who are in distress over their inability to train in a consistent manner. In the vast majority of cases, most runners seeking my services have already tried everything under the sun (to no avail) as they desperately attempt to keep training before they break down, accept their situation, and come knocking on my door. Before delving in to my physical therapy evaluation, I always make it a point to first speak with them about their injury and unique presentation in an effort to help them reconceptualize their situation while mitigating threat to their livelihood as a runner. To this end, I thought it would be helpful to share three simple reminders that I often bring up in conversation while working with injured runners.

1. MOST RUNNING RELATED INJURIES ARE NON-TRAUMATIC
When considering the injury patterns among runners, the research clearly demonstrates that the vast majority of running related injuries (RRIs) are non-traumatic in nature. This is great news because it's not as if you were tackled and sustained an ACL injury or that you dropped a heavy weight on your foot. So put your mind to ease and realize that things are not that bad considering the fact that there was no overt trauma.  

2. THE BODY HAS A REMARKABLE AFFINITY TO HEAL -
As a runner, chances are that you are in relatively good health as a function of your training and active lifestyle. With that said, your body has a remarkable affinity to heal irrespective of your age. While some runners may possess certain co-morbidities that may delay the recovery process, most runners will rebound from injury in a timely manner provided that they remain pro-active, work with a running injury specialist, and make good decisions during the recovery process.

3. RUNNERS ALMOST ALWAYS RESPOND TO CONSERVATIVE TREATMENT
In providing care for hundreds if not thousands of injured runners at this point in my career, I've never personally worked with a runner, who went on to require surgery to address a RRI that was non-traumatic in nature. This is good news provided that you connect with a rehab professional, who specializes in managing injured runners and prepares you for a safe return to training. If surgery, pills, and injectables are offered as a viable solution or long term fix, make sure to get a second opinion. While such measures can provide short term relief, they typically worsen the situation and only serve to prolong an otherwise timely recovery.

See you on the streets!

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How To Avoid Buying Defective and/or Ill Fitting Running Shoes

3/30/2015

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One of the beauties of running as a sport is that there are relatively few equipment considerations and barriers to participation. All most runners need are shorts (or leaf), a t-shirt or sports bra, and perhaps socks and shoes unless you prefer to go barefoot. As a physical therapist, coach, avid runner, and triathlete, Im well aware of the potential threat that ill-fitting or defective shoes pose to your livelihood as runner. In an effort to help you ensure proper fit while avoiding a lemon, I thought that it would be helpful to provide you with a relatively short video (see below) that goes over several key concepts related to shoe fit and screening. Hope this helps you find your ideal pair of kicks.  
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Pacific Northwest Symposium Recap - My 1st Trip to Portland

3/19/2015

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Portland Skyline
Pacific Northwest Orthopedic & Sports Medicine Symposium 2015
In early March, I had the distinct privilege to be involved as a presenter and attendee at the 2nd annual Pacific Northwest Symposium put on by Empiridence Seminars. This topic of the symposium was the lower extremity and the focus of my pre-conference and platform presentations related to running injury management. After being invited to speak, I soon realized that I would be among some heavy hitters in the medical and rehab field between George Davies, Greg and Vicky Johnson, Dr. McClanahan, Matt Walsh as well as many others. Needless to say, I had my work cut out for me and could not disappoint.

After a beautiful drive down to Portland on a sunny Friday morning, I connected with Karl Kolbeck, who heads up Empiridence and was the mastermind (along with his wife and amazing team) behind this event. Im not sure how Karl found the time for lunch given the associated duties of running a conference, but somehow he managed to make time for me (THANKS KARL). After getting some spring rolls from a vendor at a courtyard filled with food trucks, we talked shop for a while before touring Pettygrove Physical Therapy & Sports Rehabilitation while meeting some of his staff. To no surprise, his facility was amazing. After wrapping things up I ventured over to the Doubletree Hotel where the event was being held. 


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Return to Running Checklist for Runners Rebounding from Injury

3/18/2015

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Running is a repetitive plyometric activity that involves a specific set of performance demands. Therefore, clearing injured runners for a safe return to training following injury should be premised on such demands. In the event a rehab professional fails to adequately prepare a runner for a safe return to training, the runner will invariably blow up only to find themselves hobbling home. In an effort to safeguard against such a situation, I thought it would be helpful to share my criteria/checklist to help rehabilitation professionals return injured runners to training in a safe and timely manner. Hopefully this provides you with a simple and objective framework in helping injured runners seeking your services. 
                                     STRONGER - FASTER - TOGETHER

1. BASIC UNDERSTANDING OF PAIN SCIENCE 
2. NO SIGNS NOR SYMPTOMS OF INFLAMMATION
3. ABILITY TO FULLY WEIGHT BEAR THROUGH THE AFFECTED EXTREMITY 
4. ADEQUATE TOE DEXTERITY
5. ABILITY TO BALANCE ON EACH LEG IN A WOBBLE FREE MANNER
6. IDEALLY 30+ DEGREES OF ISOLATED EXTENSION AT THE 1ST MTP
7. ABILITY TO PROGRESS THE LEG OVER THE FOOT (>20 DEGREES OF DF)
8. TOLERANCE TO OPEN & CLOSED CHAIN LOWER EXTREMITY CONTRACTIONS
9. GOOD FRONTAL & TRANSVERSE PLANE CONTROL AT THE TRUNK & HIP
10. TOLERANCE TO FITNESS WALKING (3.5MPH)
11. TOLERANCE TO A PROGRESSIVE WALK-RUN ROUTINE
11. ABILITY TO HOP ON EACH LEG IN MULTIPLE DIRECTIONS
Running Check List

Injured Runner
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Top 10 Sayings I Use In Working with Injured Runners

3/16/2015

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Every day I find myself working with injured runners in an effort to return them to a float phase. During my treatment sessions, I inevitably sound like a broken record. Below is a list of the things I commonly find myself saying to clients seeking my services. Drum roll please....

1. Don't worry, you are just suffering from a simple case of RSS..."Runner's Stupidity Syndrome."

2. Believe it or not, running is a skill that needs to be learned.

3. Novice runners are more fragile.

4. Stiffness is your friend and enemy.

5. Eccentric & concentric actions work in a complimentary manner.

6. Forefoot or reafoot strike pattern isn't much of a concern to me provided that you don't overstride.

7. You are only as good as your last injury and the extent that you rehabbed it. 

8. Expect strike asymmetry with track runners. 

9. Gluteus medius timing is more important than strength when it comes to running.

10. If you have phenomenal ROM you better have phenomenal strength and control.

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Four Square Hopping Drills for Runners - The Final Frontier

12/23/2014

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Four square hopping is an exercise that I often incorporate into the late stages of the rehab process in working with runners rebounding from injury. This drill challenges the runner from a plyometric and neuromuscular control standpoint. If the performer demonstrates proficiency with this drill I'm confident as their therapist that they are prepared to initiate a graded return to running program. Once they have mastered the baseline drill they can progress to hopping without pausing  between each jump as is seen in the second video. Prerequisites to perform four square hopping include the following: 1) no signs nor symptoms of inflammation, 2) ability to fully weight bear through the previously injured region, 3) ability to balance on each leg in a wobble free manner, 4) ankle dorsiflexion of 20+ degrees with the knee flexed 45 degrees, 5) tolerance to eccentric closed chain contractions of the quadriceps, 6) adequate control of the lower extremity in the frontal and transverse planes, and 7) adequate hip and trunk control. Lastly, ensuring the runner is in an appropriately cushioned and defect free shoe is helpful in the case of awkward landings. 
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Marching with Ankle Weight on Head

12/12/2014

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This video demonstrates a slow motion thigh high marching drill with an ankle weight positioned on my head. Not only does the ankle weight provide the performer with feedback regarding their postural stability in single leg stance but it's also a quick way to find out if you've mastered the drill. No need to use anything more than a 3-5lb ankle weight. If you have more hair than I do, consider using a hat for increased friction to prevent the weight from falling off. Wishing you happy, healthy, and mindful training.
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DISCLAIMER: This site is oriented to my opinions and thoughts regarding various performance and rehabilitation subject matter. Please keep in mind that application of this material is a personal choice, and in no way is the author responsible for those choices. Readers are encouraged to only operate within their scope of practice. Examination, treatment, intervention, and rehabilitation for athletes should only be performed by a licensed medical professional.