What does the running assessment look like at PhysioWorks?
A running analysis at PhysioWorks is a 90-minute appointment during which I am busting my tail to get everything done! I talk to the client about their issues/concerns and history, I do a top-to-bottom physical assessment, video analysis, and then provide tailored recommendations to the athlete. To be honest, given everything involved, I am debating whether it should be a two-hour session!
So, this is a bit more than just video analysis!
Yes! Video analysis on its own can be helpful. However, when faced with larger biomechanics problems, pain, or injury, the analysis needs to be combined with the physical assessment to get to the bottom of the issue.
What questions do you ask at the beginning of the assessment?
When I book the appointment, I send the client electronic forms which capture their demographics, history, and goals. They can do these before the appointment, and then I can prepare in advance and then focus my questions on specific points or gaps in the story. As well as the typical medical information, these forms are customized to be running specific, so there are questions about footwear types, orthotics, race history, cross-training history, warm-up/down routines etc. This approach allows me to get a full understanding of where the client is at and what the client is looking for from the analysis.
What does the physical examination involve?
- Observation and screening:
- As soon as the client enters the clinic, I watch how they get up from the waiting room, how they walk, and how they sit. This informal observation is helpful as some patients change their posturing when they are aware the therapist is doing analysis. While we sit and talk, I take some time to look at the shoes or orthotics they have brought with them looking for particular wear patterns etc. I then ask them to stand and I start looking for notable postural patterns, particularly extremes. Examples being flat feet (pes planus), sway back posture, knock knees (genu valgum). That said, there is a lot of debate to how useful static analysis is for a highly active task such as running. However, the key is to keep what you find in the back of your mind as another piece of the puzzle!
- Next I complete the screening exam. There are many ways of doing screening exams. Some people like systems such as the Functional Movement Screen (FMS) or the Selective Functional Movement Assessment (SFMA). The aim of screening is to identify what specific, more detailed examination needs to be done. I tailor this process to the individual patient and sport. Examples of screening tests I may perform include the following:
- A single leg squat test - assesses balance, does the knee fall valgus etc.
- Plank testing - three stages of prone and side plank testing to screen for muscle endurance and postural control.
- Detailed examination
- Hopefully our screen has identified a couple of areas that need more detailed examination. For example, during the single leg squat, clients often fall into valgus because of weakness around the gluteals, so our examination will look at the hip in more detail. Here I will pay particular attention to muscles I may have concern about such as gluteus medius and maximus. I may look at flexibility around the hip to determine whether a tight muscle is making it hard for other muscles to work correctly. An example being a tight hip flexor limiting hip extension, which limits the ability and range through which glut max can be strong. There are many possibilities here, which is why all the previous examination is so important.
What does the video analysis involve?
I have my clients spend a little time warming up on the treadmill and then increase pace to approximately 10% off of race pace. I then use TEMPLO to capture 40-60 seconds of video. Then, while the client warms down and stretches, I start my analysis of the video. I use a gait analysis tool from the University of Virginia1 to systematically review the footage from both the front and the side. This tool helps to provide consistent analysis both from visit-to-visit and client-to-client. I use the TEMPLO software to record each interesting finding in a report, drawing angles, taking measurements, and making comments. I email a copy of the report to the client after the appointment. An example of a couple of pictures from the report are below:
You can see that in both sides mid-stance phase there is hip adduction. This is worse on right than left. Likely links to gluteal and lateral abdominal weakness. Correspondingly marked on the visual gait analysis tool (Below).
So you’ve completed this process of examination and video analysis, what’s next?
Next, I pull together all of what we have found in a way that the patient will understand and find encouraging. If necessary, we discuss treatment options. I try to give the patient as much control as possible, using exercises and cueing strategies, so that they are an empowered, active part of the treatment process. In limited cases, I will use other treatments such as taping, manual therapy, etc., but I try to ensure the patient is not dependent on these treatments (Check out my thoughts on Kinesiotape here!)
From an exercise standpoint, I initially start my clients with a small number of specific exercises for the muscles we have found to be weak/tight. When they return, I review their strength/flexibility measures and assuming they are progressing, I move onto exercises that I consider to be “motor-control” exercises. An example of a motor-control exercises would be a lunge with trunk rotation where you are looking to stop the knee from falling into valgus, or varus against the destabilizing force of the trunk turning above. Motor-control exercises are what help to apply the strength gained in the specific exercises. Without these, I do not think the specific strengthening exercises would have much effect. One other aspect that fits with the motor-control exercises is cueing, and is likely something many people are not familiar with. You can use internal or external cues, but research seems to be showing the latter as having more benefit. A recent example of this in the research3 is using the external cue of a mirror in-front of the treadmill to help retrain the knee dropping in to valgus. This study found this was successful in reducing patellofemoral pain in runners. Another example might be running on the track and straddling the white line to make sure you are not crossing over and running too narrowly.
How often do patients return to the clinic?
This varies, I do not do 2-3 x week for 3-4 week therapy… The key to success is tailoring the treatment and follow-up to the client. In my experience, when many people go through therapy with several appointments a week over a month, they end up with too many exercises, they get lost and discouraged, and they stop.
My goal is to see the client as little as is required to get them better. How I define this depends on why they have come to see me, their goals, and what I have found in the assessment. A couple of examples show how this might look:
- A patient comes in with a knee injury, and needs more supervision of progress. They come in once a week for the first month. They then return every two weeks for the next month, and then return after a final month. may come more regularly and may need different types of treatment. They then may return at the six-months mark for final video review. Notice that I am increasing the length of time away from the clinic so that they are depending more upon themselves.
- A patient comes in looking to reduce their injury risk and improve performance. The issues they have are less extreme and they do not need as much monitoring. They are more likely to be in a position to be given a few specific and motor-control exercises straight away. They will likely come back somewhere between 2-4 weeks. Further sessions may be warranted based off of reassessment, but I usually recommend that it is worth reviewing their gait under camera again at six months.
I have been a therapist long enough that I feel I am generally pretty good at setting realistic goals and follow-up schedules. However, I always ensure that clients know they can contact me with questions, and we can adjust our follow-up schedule as needed to respond to any concerns or findings from reassessment.
If you'd like more information about how a running analysis software could help your practice, contact us below!
- O'Connor FG, Wilder RP, Nirschl R. Running Medicine. Healthy Learning; 2014.
- Willy RW, Scholz JP, Davis IS. Mirror gait retraining for the treatment of patellofemoral pain in female runners. Clin Biomech (Bristol, Avon). 2012;27(10):1045-51.