Running-specific strength training--it makes (postural) sense!

Personal experience supports the concept that running injuries can be treated in many different ways. The most appropriate and efficient way to manage these injuries is through respecting the healing tissue, retraining the tissues to perform a function, and then making those tissues stronger and more powerful in order to perform at one's best. This path is easily demonstrated through sport-specific strength training for running injuries.

[ILLUSTRATION OMITTED]

In our clinic, we train patients through functional activities that mimic the action of running throughout the healing process. This is done through closed-chain kinetic activities, postural drills and plyometric exercises. The difference with this approach, compared to more traditional physical therapy intervention, is the specific goal of returning to running with increased strength and power and an improved dynamic postural awareness. These functional activities are discussed below.

Closed-chain kinetic exercises involve activities where the distal aspect of the extremity is fixed to a stationary or moving object. This causes a co-contraction of the extremity's musculature, representing a more functional form of strengthening. Compare this to an open-chain kinetic activity, where the distal aspect of the extremity is not fixed, as in the case of non-weight bearing leg extension. This open-chain activity isolates the quadriceps muscle, but this particular isolation is not seen anywhere in the running sequence.

Postural drills are introduced early in physical therapy intervention to fine tune proprioception and establish a neuromuscular connection. The development of this connection establishes internal cues, reinforcing an efficient posture. Plyometrics are used to develop power and speed secondary to the explosive eccentric-concentric muscle shortening relationship. To promote greater running efficiency, plyometrics help the patient gain an understanding of running technique, coordination and balance.

Each of these interventions is used in combination with the right timing as the running injury heals. Not all patients complete all stages, or they may progress through the stages at varying rates. In some cases, patients are seen only to manage the more acute by-products of their injury. However, a well-rounded program, progressing through all of the stages, helps the patient recover to a stronger, more injury-resistant and posturally aware running form.

An injured structure goes through different phases of healing, starting with the acute injury. Stage 1 involves temporary rest from the insulting activity, ice, compression, elevation and early range of motion of the injured structure. In Stage II, we regain flexibility of the running musculature, including hip flexors, extensors and rotators, and knee and calf musculature--but not forgetting the head, neck and shoulder musculature. Patients also learn an awareness of positional posturing at this time. They will require this foundation with subsequent exercises for balance, coordination, strength and speed.

Stage III begins the strengthening phase. Using closed-chain kinetic activities, the patient builds upon his postural and proprioceptive exercises to reinforce a new neuromuscular connection. Visual and tactile cues, resistive tubing and external challenges on various surfaces begin improving the patient's mind-body connection, as well as strengthen muscles in a functional pattern.

Stage IV involves the return to running. Using the treadmill and gait analysis, the patient puts together all of the different stages of their physical therapy. Efficient running strategies called "glides" are used to increase balance and coordination. "Accelerations" (progressively increasing running speeds) will promote muscular strength and speed. Plyometrics are incorporated to improve power in the running muscles. All of these different stages of training will return the patient to a better level of function with an increased confidence.

[ILLUSTRATION OMITTED]

Case Study

Craig, an amateur marathon runner, was seen in our clinic two weeks prior to his first marathon, having strained his hamstring during a long run. This was three days after the injury had occured. Since he was in Stage I of healing, he was instructed to rest from running. He then was treated with therapeutic pulsed ultrasound and cold modalities, and performed biking activities to maintain his cardiovascular conditioning for the upcoming race. One week following the injury, gentle flexibility exercises were added to improve hip and knee ROM as well as hamstring, hip flexor and calf muscle length. He went on to complete his first marathon two weeks after this injury with a finishing time of 4:30.

Craig was again in the office several months later after another hamstring strain during a long run. He had eight months remaining before his next marathon, which allowed us some time to proceed through all the stages of intervention. As before, in Stage I, while maintaining cardiovascular condition, he endured therapies that included decreasing the inflammatory response of the tissue. In Stage II, he continued to restructure his running posture and proprioceptive sense through postural drills. By this time, the hamstring tissue appeared free from inflammation and was pliable enough to begin strengthening.

The major focus of the following stages was the patient's foot position on the body and kickback power. Stage III commenced with the foundation of an erect posture learned in Stages I and II, and began with high kicks using resistive tubing. Craig stood unilaterally on the injured limb with the resistive tubing around both ankles. Keeping both knees together, he drove his involved leg's heel toward his buttocks. This exercise isolates the hamstring musculature in the kickback phase of the running sequence. He continued this exercise for several minutes in order to promote strength and endurance through the once injured tissue.

As Craig continued to make improvements in his running posture and in the strength of his involved leg, he began to run. We eased into Stage IV with a simple program to transfer activities that had been performed statically to the dynamic activity of running. After 10 minutes of walking warm-up with correct posture, we observed him on the treadmill with a 1-minute run, 4-minute walk. During this observation, we instructed Craig on the importance of foot position, kickback and proper postural awareness. We also instructed him on gliding--finding that efficient and effortless running posture through balance.

During his run transitions of the run/walk phases, Craig challenged his balance by keeping his hands on top of his head and leading with his pelvis, all the time maintaining balance over his feet. We then added arm-swinging in front and in back of his body, displacing his center of gravity. Next, he swung his arms straight up and back to highlight the difference between all of these positions, while observing that the last position was the most efficient. Craig was instructed to try pointing his toes out, in, and then straight. As his postural and proprioceptive senses improved, he noted that he was most efficient when his body was balanced, leading with his pelvis and with arms swinging directly up and back; he also noted that his toes were pointed straight ahead.

Craig continued to demonstrate an appropriate response to the running exercises. He progressed to 2-minute run, 3-minute walk; 3-minute run, 2-minute walk; 4-minute run, 1-minute walk, etc. At this time, he began to attend the group track sessions offered weekly through the Miami Runner's Club. It was during this time that we aimed to make Craig a stronger runner than he was before coming to our clinic. We have a treadmill in front of a mirror so that patients can view their technique while performing exercises. We then slowly transition them away from this into areas where they cannot use visual cues and must rely on their proprioceptive senses. The track is an optimal way to continue advanced levels of rehabilitation while integrating all of the other stages of therapy.

On the track, we began to work on accelerations. For Craig's hamstring muscle strain, we focused on a straight foot position. He was asked to run 100 meters, starting slowly with a full foot gait and progressively running faster to an all-out effort that used only the fore-foot, with a focus on kicking back during the swing phase. As he continued to progress with his running form and strength, he became ready to commence plyometrics to increase the power of his running stride.

Plyometrics are explosive movements that use energy created by the relationship between quick eccentric and concentric muscle movements during a given activity. These explosive movements occur for short distances during which the overall goal is quickness, not amount of distance covered. During Craig's training, he initiated exercises such as "high kicks," which he ran with an erect posture, bringing one heel backward toward his buttocks in one quick, powerful movement. "Unilateral-legged high kicks" were next, focusing on one heel coming toward his bottom while the other leg took a natural running stride. Finally, a "high kick two step" promoted coordination and balance while developing power and speed. (Start with a right-legged high kick, take two running strides, and then perform a left-legged high kick; take two running strides and repeat.)

By the end of this rehabilitation, Craig had learned how to manage the acute phase of a running injury, restructure his running posture and progress the once-injured muscle to a level of fitness that he had never before encountered. Craig entered the next marathon feeling confident with his new running style and strength. He returned with a PR of 3:40, 50 minutes off his original marathon time! Although the PR felt great, he reported feeling an even greater relief that he was healthy afterward.

In our experience, runners do well when physical therapy is structured to meet their particular sport. Implementing sport-specific strength training into the basic physical therapy intervention provides more goal-oriented outcomes. Physical therapists must respect the healing tissue when an injury first appears, but proprioceptive and strengthening exercises eventually can and should be initiated. The additions of more advanced dynamic activities allow the patient to become even stronger and more powerful than they were prior to injury. These experiences have assisted our runners in achieving their personal race goals with confidence. You too can rehabilitate injuries in this way, as well as influence others to initiate sport-specific intervention--the proof is in the PR!

by Bruce R. Wilk, P.T., O.C.S., Megan M. Greco, D.P.T., A.T.C. and Jeffrey Stenbeck, P.T., O.C.S.

Bruce Wilk, Megan Greco and Jeffrey Stenbeck are physical therapists at Orthopedic Rehabilitation Specialists in Miami, FL.