Thursday, November 24, 2016

Mizuno Wave Rider 20 Review

The Mizuno Wave Rider was my training shoe of choice for years while racing in college and post collegiately.  When I heard the Wave Riders were getting a complete makeover, I was so excited to check them out. As a Fitfluential ambassador, I got the opportunity to review the new Wave Rider 20. 

Running shoe companies like Mizuno have continuously evolved their running shoes as new technology is developed, and this newest iteration of the Wave Rider is no different. The Wave Rider  showcases their new Cloudwave Geometry,  a new midsole and updated mesh.

Although the Wave Rider is categorized as a "neutral" or "cushioning" shoe, the Rider provides a level of ground response that makes these shoes feel more alive when running, and enough support which kept my foot on an even keel after stepping on a rut on the road or a rock on the trail. This does not mean that the shoe lacks cushioning; The legs rolled on and the miles kept accumulating without excessive fatigue associated with shoes that have gone thin. It is not a stretch to say the feel of this shoe is attributed to the new Cloudwave Geometry, it certainly did not make it worse. 

The fit is amazing! Through long runs the Wave Rider feels snug without rubbing my feet. The tongue stays up providing a nice padding for the front of the ankle through rolling hills. 

The only real critique is that while the shoe is responsive, the Rider has a heel bias typical with shoes of this type. During fast interval runs or runs trying to maintain mid-foot strike, this shoe can feel cumbersome, even tiring.

Overall, they provide great support and cushioning for most of my running up to fast tempo runs. 

Note: I received these shoes for a review at a small fee.

Wednesday, June 29, 2016

Hydration and Performance Gels/Drinks

As the weather is getting warmer as summer begins. The key to a successful long run or race is good hydration and sports performance gels/chews. This is especially true for long distance runners. Since returning from the Western States 100, I thought it is a perfect time to discuss this topic. I started running in an era that sports gels and hydration packs were just blossoming, so it has been a learning experience over the years. I remember when Power Bar came out with Power Gel and tested it at Stanford Cross Country Invitational (1996?). Then hydration packs became more popular (2000?).

It seems very simple. Drink water... Or is it?


Dehydration is a common ailment among athletes. This occurs when there is more fluids lost then ingested. Athletes, of course, are most vulnerable during intense exercise in the heat or in cold weather when athletes don't feel as thirsty. Newer athletes may be more susceptible to dehydration as they may not be as adjusted to drinking the amount of fluid they need. For runners, it can be difficult to carry water and the desire to keep running over powers stopping for water. However, proper hydration allows the body to function properly. The current guidelines is about 4-6 oz of fluid for every 15-20 minutes of exercise lasting > 30-45 minutes in duration. 1 gulp of water is 1-2 oz of fluid.

Signs and Symptoms 

In mild to moderate cases dizziness, headache, confusion and cramping are some signs and symptoms. In severe cases the athlete stops sweating and blood pressure decreases.


The condition that is less heard of is hyponatremia. It translates to too little sodium. This occurs when there is too much fluid and not enough electrolytes. The first time I heard this was my senior year in high school when a former California State Champion (competing at Stanford) couldn't finish her race because she drank too much water and her electrolytes were imbalanced. She drank 1 gallon of water before her race.
Runners who run longer then 4 hours are more susceptible to hyponatramia. Since they are on the course longer they tend to take in more water not realizing that sodium is important too. To avoid dehydration runners will drink water at every aide station. However, ingesting more water compared to how much you are sweating will increase the chances of becoming hyponatremic.  This will increase the amount of water in the body but the sodium level decreases from sweating causing hyponatremia. An improper balance of water to electrolytes can cause a number of different symptoms and can lead to coma. This is why it's important to have sports drinks along with water.

Signs and Symptoms

Headache, nausea and vomiting, lethargy, and confusion, seizure are symptoms of hyponatremia.
The excess fluid moves from between cells to inside the cells causing the above symptoms. When it is severe it can move fluid into the lungs and brain.

Dehydration vs Hyponatremia

The symptoms of dehydration and hyponatremia are very similar. In the past, the best way to monitor is to weight your self before and after running. If you weight less, there is less water. You're dehydrated. If you weight more, this means have you're over hydrated possibly leading to hyponatremia. However, this way of checking is unreliable. The latest research supports moving away from using weight as the sole monitor.

You can be dehydrated AND hyponatramic (weighing less). In the past, the athlete would have been given more water. However, drinking more water can further put you in hyponatremia.  Being more aware of your hydration strategies is the best option. Make sure you drink a adequate balance of water and sports drinks/gels.

Sports Drinks, Gels and Energy Chews

For long distance events (> 60 minutes), sports drinks, gels and chews are important to provide your body with energy and keeping a good electrolyte balance. They contain a specific percentage of carbohydrates.  Research shows that 6-8% carbohydrates is the best for the stomach to absorb. A 100ml drink should have 6-8 grams of carbohydrate or 14.2 - 18.9 grams per 8 oz of fluid. Higher percentage decreases gastric emptying which leads to gastrointestinal stress (cramping, vomiting). With the increase in GI stress, the amount of fuel being delivered to the muscles is decreased. So you're left with GI issues and lead legs. Fruit juices and soda contains 10-12%. They can contribute to GI stress if they are not diluted.

If your gel pack states to drink 6 oz of water. Drink 6 oz. of water. This ensures the proper percentage of carbohydrates. That is 3-6 gulps of water per pack. If you ingest multiple gel packs, let's say 3 over an hour, that would be 18 oz of water which can be a lot if you're not use to it. Or, if you drink a performance drink with the gel, it will increase the concentration of  carbohydrates to an undesirable amount. If you're not use to drinking water with your gels or chews and/or use more then you would typically, you can be causing GI stress on race day.

For example- A GU pack typically has 22 grams of carbohydrates, you should have approximately 10 oz of water with the GU for proper percentage carbohydrates. If you ingest 2 packs, you should have 20 oz of water.

Of course, everyone is different. Some athletes feel fine with more or less then the recommended amount. Know your body. If you end up with GI problems you can rebalance your body by drinking more water if you have had a lot of sports performance drinks/gels or taking more sodium if you haven't had electrolytes with your water.

***These are the basic of hydration and performance aides. There is a lot more detail such as protein ratio, caffeine, etc, but would make this post into a book. Please contact me if you have further questions.

Leiper JB, Prentice AS, Wrightson C, et al. Gastric emptying of a carbohydrate-electrolyte drink during a soccer match. Med Sci Sports Exerc 2001;33:1932-1938. 

Murray R, Bartoli W, Stofan J, et al. A comparison of the gastric emptying characteristics of selected sports drinks. Int J Sports Nutr 1999;9:263-274.

Sunday, May 29, 2016

Posterior Tibialis Tendonitis

Tibialis posterior tendonitis is an injury that affects a few runners a year. This injury affects mostly people who have pes planus ( flat feet) and/or over pronate. Tibialis posterior tendinitis is painful on the inside of the foot and ankle region. The most stress is during mid-stance, when body weight is fully on the foot. 

What contributes to Tibialis posterior tendonitis?

Limited ankle dorsiflexion

Dorsiflexion is the movement of your foot towards your body, or in standing, when the shin bone moves over the foot. Dorsiflexion is required for proper walking and running mechanics. When the ankle is limited, the body makes up the motion elsewhere. One compensation is the foot splays outward. This will increase stress to plantar fasciitis and posterior tibialis tendon. Over time, the stress leads to injuries of those structures as it is unable to tolerate the load.

The top picture shows the ankle joint when the foot is pronated.
The bottom picture shows the ankle joint when the foot is
supinated. Less ankle dorsiflexion is shown when the foot is
pronated. The motion is taken up at the foot stretching the
tibialis posterior.

What contributes to limited ankle dorsiflexion? 

High Heels

When you wear heeled shoes, the foot is constantly pointed downward in plantarflexion. Over the course of the day the ankle joint progressively stiffens in that position. Even if you’re sitting with your shoes on, the foot is always pointed down. When you are out of the heel shoes and in running shoes, your heels are now closer to the ground. This requires more dorsiflexion at the ankle joint and muscle length of the calf. In order for the body to move over the foot,  the ankle needs to bend. But when ankle dorsiflexion is lacking, the motion is achieved by bending at the foot, specifically the navicular bone. This is the bone which the tibialis posterior tendon attaches to. With each step, the tendon is getting stretched. Over time this strain leads to tendonitis.

Prior Injuries 

Have you ever had a mild ankle sprain that you just ignored? There was a little swelling and pain but symptoms subsided. The swelling limits your ankle mobility and within a couple of days your ankle will get stiff. Your body compensates by getting the motion in your foot. Over time the mobility of the ankle will be more limited. Like above, the tibialis posterior tendon gets stretched. 

Weakness of Glutes 

Our body is connected by muscles, fascia and bones. If there is weakness in one region, it can affect another body part several joints away. The gluteals can affect the ankle. One of the functions of the gluteals is to externally rotate the thigh. Since the femur is attached to the shin, the lower leg bone will lift the arch up when the glutes contract. When the glutes are weak, the femur rotates in, which causes the lower leg to rotating in. This will allow the arches flatten. Try this at home.  Squeeze your glutes and watch what your foot does. 

Pelvic Mal-alignment

The pelvis is made of the ilium on each side and is separated by the pubis in the front and sacrum in the back. The ilium moves independently but one side affects the other.
When the pelvis is rotated, the hip socket, which is on the illium, moves up or down relatively. This affects the entire leg. When one illium rotates backwards, it makes the leg longer and the other leg shorter. This is called a functional leg length discrepancy. There there is actual difference in the length of the leg bone, it is called anatomical leg length discrepancy. This causes a problem for the body because it wants to stand level. The side that longer will pronate while the side that is shorter will supinate. The prolong pronation will stretch the tibialis posterior tendon. 

Placing the book under my foot, makes my leg functionally longer. My right foot is
pronated and the heel is angled away. 

Running Form 

Landing excessively on the outside of
the foot increases stress to the Tibialis
Posterior tendon.
Landing equally across the foot decreases
the stress to the Tibialis Posterior tendon.

Normal running form is to strike the ground on the outside of the foot, then roll to the inside. This is called pronation. However, some runners strike the ground too far on the outside portion of the foot.This places a lot of stress on the tibialis posterior tendon whose role is to slow down pronation. The more the foot strikes on the outside,  the tibialis posterior has to work more to control the motion. 


1) Improving ankle mobility and strength will decrease strain on the tibialis posterior tendon. Follow the video in this blog post

2) Gluteal and core strengthening program is important to indirectly control the lower leg. There are numerous post on how to strengthen the core. The core video in this post is a great progression. 

3) Correct a pelvic malalignment

Put your hands on your hips and feel for a bony landmark on each side with your thumbs. This landmark is called posterior superior iliac spine, PSIS for short. If your right side is lower, that leg is functionally longer (shown above). If your left side is lower, that leg is functionally longer.

To correct a right posteriorly rotated SI joint, we are going to use the right hip flexors to rotate the illium forward and counter using the glutes/hamstrings to rotate the left side backwards. Lay on your back with your knees bent. Bring your right leg up and use your hands to resist at the knee. At the same time dig your left heel into the ground. Hold this for 6 seconds and repeat 3 times. Next take a hard object ( I like using my foam roller) and squeeze between your knees for 6 seconds 3 times. 

4) Form
Practice landing with equal force across the foot. This decreases the distance the medial side part foot has to lower to the ground which will lessen the stress to the tibialis posterior tendon.

These are some of the contributing factors I look at when assessing a runner with tibialis posterior tendonitis. 

Please let me know if you have any questions.

Saturday, April 30, 2016


Sciatica is a common injury that can impact up to 40 % of people at some point in their lives. For runners, it can be devastating as it impacts training and preventing participation in the "goal race". Sciatica is merely a description of a symptom, which is inflammation of the sciatic nerve. It does not provide a cause. The sciatic nerve can be pinched in the hip region or the back. This article is going to focus on the back. There is an article I wrote which discusses how ankle stiffness can lead to sciatica.

A  number of nerves exit the spine and come together to make up the sciatic nerve. The nerves exit between lumbar spine 4- sacral spine 2. It travels through the pelvis and descends down the back of the leg. Pinching of the nerve causes pain, numbness, tingling and if severe enough, loss of strength.  There is a distinct pattern of pain, weakness and loss of sensation which allows the clinician to know which nerve root(s) is affected.


Herniated disc

A herniated disc is when the disc between the spine pushes into the space where the nerves live. Due to the the structure of the disc, the soft material gets pushed backwards onto the nerves. This usually happens when the body is forward flexed and there's a force. Squeezing or coughing while bent forward is a common way to sustain this injury. When the disc is herniated, any sitting or bent forward position increases pain. This position puts more pressure onto the disc which pushes onto the nerve.


This injury occurs when the space the nerve exits the spine narrows. This happens when the disc looses it height or when the arthritis in the joint. When the disc loses it height the ligaments surrounding the spine buckle which takes up space where the nerves are. Imagine a curtain on a wall and what it would look like if the ceiling height got lowered. The curtain will buckle. This type or injury gets inflamed with upright activities and be more comfortable sitting.


Alleviate the pain

This is the 1st step! The body will compensate and muscles are shut off when there is pain. Number one goal is to decrease the pain to allow the nerve pathways to the muscles. This can be achieved by using ice/heat, resting positions and taking pressure of the nerve.
People often think they are improving because their pain is decreasing. In reality, they may not feel pain because MORE nerve fibers are being pinch and they are losing sensation. Eventually the muscles no longer get the signal from the brain and will get weak.
For a true herniated disc, laying on your stomach will help to take pressure away from the disc. These are known as Mckenzie Extension exercises. While for stenosis, sitting or laying with the legs at 90 degrees will allow opening of the joints. These are called William Flexion exercises.
Traction in these positions will further accelerate the healing process.

Core stability

Focus on developing the muscles that stabilize your spine not move your spine. People have a tendency to perform big movements like back extensions and sit- ups. However, when your back isn't stabile these movement can contribute to shearing of the spine leading to early degeneration arthritis. Poor posture allows the core stabilizers to atrophy. Bigger muscle groups function as stabilizers. This contributes to nerve pain as the spaces narrow.

Mobility Above and Below

You want to make sure the area above and below the region is strong and mobile. This helps to take the pressure of the spine. Often the areas above and below a painful segment is stiff and tight which forces the injured area to move more. This leads to over use and also lead to early arthritis
Most commonly the thoracic spine and hips have limited mobility.


The hips and pelvis are important region as it serves as a base for the lumbar spine to sit on. However, it's mobility is often limited. When I walk into an exam room, I see my client's back rounded. To improve posture, hip mobility needs to be assessed.

Good sitting form: Hips are at approximately
90 degrees and back has good curvature
Poor sitting form: Hops are rounded forcing the
back to round.

They are unable to get > 90 degrees of flexion in the hip. This is problematic because it leads to poor posture. There is an increase stretch to lower back, poor alignment and shuts down muscles.

Thoracic spine 

The thoracic spine area is a victim of gravity. Gravity pushes down on the shoulders while we sit and standing causing the thoracic spine to curve forward. The thoracic spine is also stiff due to it's job as the protector of all things vital... our heart and lungs. Due to the rib cage, the thoracic spine doesn't have a lot of motion compared to the neck and lumbar spine. However, this area should have the most ROTATIONAL motion of the spine. It's inherent stiffness limits mobility forcing rotational motion upon it's neighbors, the neck and low back. Have you ever heard of anyone with thoracic spine arthritis? It's highly unlikely because the low back and neck usually works harder to make up make for the lack of motion in the thoracic region. That is the reason arthritis is so prevalent in the low back and neck.

****Stay tuned for the next post! I'm traveling for 7 weeks! How to stay injury free and fit while on the road!

Tuesday, March 29, 2016

Runner's Knee

One type of knee pain is patellofemoral joint pain. This occurs when the tissues on the underside of the patella ( the knee cap) is inflamed causing pain. It plagues many runners limiting their training and sidelining them from racing. When the area is really aggravated, it can hurt to sit and negotiate stars.  The patella and the femur (thigh bone) make up the patellofemoral joint. When the knee bends, the patella slides up and down in a groove of the femur. There are several ways the patellofemoral joint can be aggravated. There can be compression from the quadriceps (which can also lead to patella tendonitis),  lateral compression from the illiotibial band (ITB) and poor mechanics.


Quadriceps Compression 

The patella 'floats' in the connective tissue of the quadriceps. The quadriceps transitions into the quadriceps tendon then attaches to the patella then becomes the patella tendon. When the quadriceps are over worked, it puts an increase pull to the tendons. The tension from the tendons compresses the patella into the femoral groove resulting in grinding. The grinding causes degeneration of the tissue  behind the patella leading to pain and arthritis.

Lateral compression 

Due to imbalance of muscles, the tissue on the lateral (outside) of the thigh can get stiff pulling on the the patella. This structure is known as the ITB. The ITB has fibers which attach to the patella. Cadaver studies have shown a variation in how much of the ITB tissue attaches to the patella. You can't stretch the ITB because it is not a muscle, it is fascia. There is no elastic tissue to stretch.  This is why foam rolling is so important ( we'll get to that in a minute). When the ITB pulls on the knee cap it cause pain on the either side of the knee cap.  The lateral tissue pull the kneecap to the outside which can  stretch the medial structures causing pain on the inside. On the other hand, the pull of the ITB can cause the knee cap to rub again the femur causing pain on the outside of the knee. Stiffness of the ITB can be a result of poor muscle activation.


"The knee is a stupid joint."- Gary Gray. It is influenced by the hip from the top down and the ankle from the bottom up. The knee comprises of the tibia (shin) and femur. These bones make up the ankle and hip respectively. Any biomechanical deviations above and below has a direct affect on the knee.

Pronation of the foot is normal in the stance phase. However, excessive or prolonged pronation leads to injury. When the foot over-pronates, the foot rolls towards the ground bringing ankle joint in. The tibia (shin bone) follows along. Since the tibia makes up the knee, the knee follows along and collapses inward. This is called the valgus position and causes abnormal stress to the knee.

From the top down, the gluteal muscles can play a role in knee pain. The gluteals originate from the pelvis and attaches to the thigh bone. When the glute muscles contracts, the femur (thigh) bone rotates keeping the knee forward. Activation of this muscle keeps the femur aligned forward and the knee in a good line of pull. However, when there is weakness of the gluteals, the femur is allowed to drift inward. This causes the knee to fall inward, again, causing increase stress to the knee.


What to do now?

Foam rolling is a type of myofascial release. The science is unclear on it's exact mechanism. My belief is the compression provided restores fluid ( think about squeezing a kitchen sponge) between the connective tissues which improves the ability for the tissues to slide. It is good at managing symptoms but will not get to the root source. There is a reason why the muscles and tissues get unusually tight. Foam rolling  is still beneficial because you want the muscles and connective tissue slide better. For quadriceps compression roll over the quadriceps and for lateral compression roll over the ITB.
*** For the optimal benefits make sure you are hydrated when foam rolling. 

Long term


Research has shown glute strength has a direct affect on knee pain. Due to the attachment of the gluteals, it has direct control of the femur.  Proper glute strength and activation keeps the femur in a forward position. This aligns the femur the the patella can stay within it's groove. This leads to less strain in the knee joint. However, when the glutes are weak, the femur is allowed to roll inward which leads to mis-aligned position increasing stress to the knee. Also, energy absorption from ground forces is more evenly dispersed to the glutes and away from the knees. I have written posts on glute strengthening exercises.

Limited ankle dorsiflexion is a contributing factor in foot pronation which can impact knee position. Dorsiflexion is the ability to pull the foot towards your body. While you are running, as your foot hits the ground, your shin moves over the ankle as the knee bents. This movement is also ankle dorsiflexion. If there is inadequate ankle dorsiflexion, the foot will pronate to compensate for the loss of movement. In a tight ankle the tibia comes forward but there is a stop in the ankle. Momentum will carry that energy forward in the form of foot pronation. Due to the bony structure of the ankle, when the foot pronates the ankle with rotate along with the tibia. This will result in knee valgus (see above picture) leading to increase stress to the knee. In order to resolve the mechanics from the ground up you have to perform ankle mobilizations to loosen up the joint then restrengthen the foot. Here is a video to demonstrate ankle exercises.


Running form has a big influence on injuries. Over striding places a bigger emphasis on using the quadriceps for propulsion. This leads over use injuries  of the quadriceps.  Over-striding brings the ground reaction forces in front of the knee creating more strain in that joint. People who over stride tend to be heel strikers. Research has shown that heel strikers have more knee pain then forefoot strikers. By heel striking, the ground reaction forces goes anteriorly placing more stress on shin, knees and quadriceps. However, forefoot running brings the body over the ground reaction forces which allows the energy to be disperse through the entire leg. This occurs because the body mass is over the foot. Meanwhile in heel strike the body is behind the knee, which makes the quadriceps work harder to propel the body over the foot.

Proper forefoot strike also works the muscles (tibialis posterior) that hold up the arch limiting the amount of pronation. This leads to better knee alignment. BUT beware, if there is weakness of the muscles you can get aches and pains in the lower leg in the transition. Having good core strength takes the pressure off the lower leg.

My recent post discusses the benefits of forefoot running.

Our body is all connected. The regions above and below the pain typically contributes to injury.

Please contact me if you have any questions.

Kulmala JPAvela JPasanen KParkkari JForefoot strikers exhibit lower running-induced 

knee loading than rearfoot strikers. Med Sci Sports Exerc. 2013 Dec;45(12):2306-13.

Daoud, Adam I., et al. "Foot strike and injury rates in endurance runners: a retrospective study." Med Sci Sports Exerc 44.7 (2012): 1325-34.

Saturday, March 12, 2016

30 day 3D Exercise Challenge

While I'm working on my next post, I'm going to do a 30 day 3D exercise challenge on my Instagram starting 3/13/15 (3drunner, also link located on the right). 

What  is 3D? Our body moves in 3 main planes of motion - sagittal, frontal and transverse ( forward/back, R/L and twist). And our muscles, joints, bones are 3 dimensional! Unfortunately a majority of us assess, treat and train primarily in the sagittal plane while the frontal and transverse planes are under utilized. In running (and walking), we move in the sagittal plane, but the other planes work to support forward movement. I think weakness of frontal and transverse planes leads to early fatigue and even injury. Performing exercises with the 3 dimensions in mind strengthens more muscle fibers!

Thursday, February 25, 2016

Exercises to Transition to Forefoot

Did I convince you to try forefoot running? Have patience, this transition should take several months. You have been landing on your heels for years, it's not going to change in a couple minutes. It takes time for your brain to change the firing patterns of the nerves, your muscles to build strength and the movement to become natural.

If you're not already walking at home barefoot, DO IT every day. Actually, think about landing on your forefoot while you walk.


Good core strength and stability is the most important aspect in maintaining a forefoot strike running pattern. Due to the inherent forward lean of this running style, the core is always engaged. The onset of fatigue leads to poor form. The chest starts to hutch over (as oppose to forward pelvis over the foot) and hips shift backwards which leads to heel striking.

For clams, side lying leg lifts, fire hydrants and bridges:

stage 1 - perform 3 sets x 12 reps
            - hold plank 10 x 10 sec

stage 2 - hold 10 reps for 10 seconds
            - hold plank 3 x 30 sec

stage 3 - add band repeat stage 1
            - progress to single leg bridges
            - add squats and lunges: use push knee back cue
            - add plank - add knee bent plank and rotation 10 each side

stage 4  - repeat 2 with band
             - continue single leg bridges, squats, lunges and plank (lunges and squat add weight or            bend knees more)

*** Perform stage 1 every day. Stages 2-4 perform 3-4 x week.
*** Do not progress stage until the current stage feels easy.
*** You should have glute soreness after each session.
This should take a minimum of 8 weeks!!! Spend about 2 weeks per stage. 

Ankle Strength and Drills

To land on your forefoot you have to have excellent calf strength. Forefoot strike puts extra stress to the calf muscles and Achilles tendon. You are performing an eccentric heel raise with each stride! These drills help with proper form and getting the neurologic input to land on your forefoot.

Calf Raises - With a twist! By turning left and right as you come up, different muscle fibers are being used. In running, the twisting motions occur when your foot lands and when it lifts off the ground. It happens so fast you can't feel it. Start with double leg 2-3 sets of 10, then at stage 3 of core, try single leg 3 sets of 10 reps.

Wall Falls - Forefoot running requires eccentric strength of the calves. Eccentric strength is when the muscle is working while it's stretching. This strength is required during the time the forefoot hits the ground and when the heel lands. 2-3 sets of 10 reps

Falls Into Strides - This takes wall falls to the next step. Fall forward until you can't hold yourself up, then stride for about 20 yards. Keep your back straight and core tight. Please don't fall on your face!

High Knees - This works on front side form. Bring your knee up to your chest without leaning backwards and land on your forefoot. Keep your feet under your body and don't reach forward. This drill is about speed not distance of each step. 10-20 yards

Butt Kicks - This works on back side form. Kick your heel towards your glutes. The tendency is to arch your back because of tightness in the quadriceps and hip flexors. Keep your core tight and back in neutral. Land on your forefoot. Again, this is about quick feet and not distance. 10 - 20 yards

Running Program

Start slow and forefoot run for a 2-3 minutes then return to your normal form for 5 minutes to allow the new working muscles to rest. Repeat until you reach 30 minutes. Increase the amount of time you forefoot running by 1 minute each week as long on there is no pain. So forefoot run 3-4 minutes then walk 5 minute.

Week 1
Barefoot walking in the house using a forefoot pattern.
Week 2
2-3 minutes forefoot running 5 minutes running normal x 3 - 4 for 30 minutes total 2-3 times a week
Week 3
3-4 minutes forefoot running 5 minute running normal x 3 - 4 for 30 minutes total 2-3 times a week
Week 4
4-5 minute forefoot running 5 minute running normal x 3  for 30 minutes total 2-3 times a week
Week 5
5-6 minute forefoot running 4 minute running normal x 3  for 30 minutes total 2-3 times a week
Week 6-12
6-7 minute forefoot running 3 minute running normal x 3  for 30 minutes total 2-3 times a week
Repeat until you reach 3 x 10 minutes of running forefoot
Then transition
15 minutes of forefoot running 3 x week
18 minutes of forefoot running 3 x week
add 3 minutes to each run each week until you reach 30 minutes.

Do not move forward if you have pain. You should be able to comfortably run forefoot for 30 minutes without discomfort before incorporating it into harder runs.

There are a lot of different core and ankle exercises, as well as, running drills. However, I believe these are the fundamentals which build a good base for forefoot running. Remember this takes time to transition!

Look out for a future post on how footwear ( heel drop) can change your strike pattern.


The core exercises are a modified version of Dr. Chris Powers's Course Evaluation and Treatment of the Injured Runner: A Biomechanical Approach

The running program is a modified version from Dr. Irene Davis's running lecture Spaulding National
Running Center - Barefoot running Training.

Sunday, February 21, 2016

Why Forefoot Strike

In recent years, there has been significant increase in the media about forefoot strike. Is forefoot running good for you? Will it lead to injury? Is it just a fad? Research seems to show forefoot strike decreases injury and improve running performance.
I was already adjusting my stride to manage my own injury. I've tried shifting my hips side to side to load my hips, but that just gave me a bunion. I tried kicking my leg to the side as it went behind my body, but that didn't work. My recent glute activation cue of "push the knee back"while running seems to be alleviating my symptoms. I also notice this cue made me strike more forward on my foot. So I decided to investigate. Here are the benefits I learned about forefoot running.

*** Forefoot strike is not running on tip toes. Forefoot running is landing on your forefoot then allowing the foot to come down.

Why Forefoot Strike? 

Decrease Forces

For every action there is an equal and opposite reaction. That is Newton's 3rd law of motion. How does this relate to running? When looking studies using force plates, there's a big difference in  forefoot strike vs. heel strike. During forefoot strike there is 1 smooth peak of force. However, in heel strike there are 2 peaks of force. This means there is more force when you heel strike.  Your muscles work harder have to absorb extra force. It doesn't seem like that extra force is a lot but if you multiple how many steps you take per minute ( ideally 180 steps) that is over 5,400 steps over 30 minutes multiplied by that extra force. By forefoot striking, you use less energy because there is less force.
This chart shows the double peak vs single peak
difference in heel strike vs forefoot strike.

Better Body Position 

Proper running form is having foot under you as your body moves over your leg with a slight forward lean from the hips. Foot placement under the body is critical because it allows smooth transition of force. The ankle is used and a spring. In heel strike, there is a "braking" involved when the foot hits the ground. Landing on your forefoot helps to bring the body forward into slight forward lean. A forward lean helps to activate your core muscles to stabilize your body while running.

In heel strike the body trails behind the leg, this causes increase demand in quadriceps. However, during a forefoot strike the body is over the leg which allows improve loading of the whole lower extremity. Clinically this is important because many injuries arise from over use of the quadriceps and under-utilization of the gluteals. Forefoot striking improve posterior chain activation.

Forefoot strike The upper torso is  over
the ankle. This allows force to smoothly
transition over the foot.
Heel strike  The upper torso trails behind the
contact leg which increases the work load.

*** TRY this: 1) In standing shift your weight towards your heels. What do you feel? I feel my quadriceps engage. Now shift your wight into your toes. What do you feel? I feel glute and core activation . 2) Walk with the forefoot hitting the ground first. What do you feel? I feel my body lean forward and my abs are activated. Now, walk exaggerating a heel strike. What do you feel? I feel my body leaning back Or my chest comes forward and my hips move back ( this creates lumbar lordosis which leads to low back pain).

Preserving  Forward Momentum 

Heel Strike - red line demonstrates gravity pushing
down at the shoulder. The line falls behind the foot.
This means your body weight is you and
your muscles has to work harder to
push you forward.
Forefoot Strike - red line shows gravity pushing
down through the foot. This gets your weight
forward which is easier for your muscles
to propel. 

To run with proper forefoot strike, you have to lean forward at your pelvis. This moves your center of mass forward over your base of support. This allows gravity to work in your favor by pushing your body forward. When you heel strike, typically, your center of mass is behind your base. You are fighting ground reaction forces and gravity to move forward. Gravity is actually pushing you backwards. It's hard to land heel strike while maintaining a forward pelvic lean. When you forefoot strike, you lean forward at your pelvis allowing gravity to help which makes you more efficient while running.


Lean forward at pelvis

When you bring your pelvis over your feet you bring your center of mass over your base. This helps to keep your feet under your body which allows you to forefoot strike. At the same time, as mentioned above, you allow momentum to carry you forward.  Make sure to keep your core tight by bring your pelvis under your body.

180 steps per min

Research has shown 180 -190 stride rate is most effective. To establish this frequency you have to take shorter strides which help with landing forefoot. When you heel strike, the length of your stride is longer making it difficult to increase frequency. A quick Google search shows Play list for songs with 180 beats per minute.

Be light on your feet

This seems obvious. But when you're landing light and soft, it's  hard to land on your heel. Landing light also decreases the time your foot spends on the ground. This will help decrease the forces your body has to absorb.


My conclusion is running with a forefoot strike is better for body alignment and efficiency. This can in turn decrease injury and improve performance. However, it requires A LOT of ankle and core strength. FOREFOOT RUNNING ISN'T FOR EVERYONE. It takes time to get your body moving in a different pattern! In order to transition to forefoot strike safety, you be have patience and have good strength. I recommend forefoot strike only if you have a GOOD core stabilization program and calf strength. It is my personal belief that some one who has pain while attempting to forefoot strike is not  strong enough to maintain this pattern.

Please have your form evaluated by a professional. It is critical that you get feedback on your form.

I am working to transition myself to forefoot running. Those who know me know I have been battling a 6 year injury from a fall. I've had numerous imaging and injections without answers or resolution. Through the past 6 years I have been able to run but always with some symptoms. Recently, I have been focusing on REALLY improving my core and glute strength because of the possibility of a hip labral tear. I have been incorporating fore foot strike into my runs focusing on proper form. I have not had ANY symptoms. As soon as I can't maintain my form my quadriceps symptoms return.




Altman, A.R.  Davis, I.R. Barefoot Running: Biomechanics and Implications for Running Injuries. Current Sports Medicine Reports. Am. J. Sports MedVolume 11 Number 5 September/October. 2012 (244-50).

Davis, Irene.  Lecture Foot Strike, Footwear, Treatment of the Foot- An Evolution of Thought.

Divert, C. et al. Mechanical Comparison of Barefoot and Shod Running. Int J Sports Med 2005; 26: 593 – 598.

Powers, C.M. Functional Biomechanics of the Lower Quarter Lecture.

Rooney, B.D. Joint contact loading in forefoot and rearfoot strike patterns during running. J Biom,V46, 13.  September 2013, Pages 2201–2206.

Monday, February 8, 2016

STOP Stretching Your Iliopsoas

It's all over the internet. You've read about it on numerous blogs. I've even talked about it. There's stretches. There's lacrosse ball rolling. There are standing desks.  It's all to resolve tight hip flexors (Illiopsoas). "The tightness is killing you!" You're doing everything you can ... But WHY is it still tight?

When we roll, stretch and use a standing desk,  are we REALLY solving the issue?  There has to be more to the story then hip flexors contractures from sitting.

Yes, sitting can contribute to tight hip flexors. However, instability of the core and back can also cause the hip flexor to be tight. The hip flexor originates from the lumbar spine. It is a massive muscle in the center of our body. When the core is unstable the hip flexor compensates by tightening to provide the stability needed. Our body wants to be stable. Could it be that our hip flexor doesn't get tight because of the position itself? Or does it tighten because the way we sit causes or back stabilizers to shut off so the hips stiffness to provide stability?

Core Stability vs Core Strength

Core stability is the ability for the small intersegmental muscles to stabilize the joints while moving. This is important for proper bone mechanics. Core strength is the ability of the large muscles groups to the body in a big range of motion. Stabilizers are the multifidus which are short muscles that attach a every 2-3 bone segments and the transverse abdominals (TrA) which is the deep layer of the abs. Strength muscles are erector spinae and rectus abdominals (6-pack).

Note how parts of the psoas originates
from each of the vertebra 
Note the attachment of multifidus spans
3 segments

Performing crunches and back extensions will improve your core strength but not stability your core. Lack of balance between the stabilizers and strength muscles can cause shearing of the lumbar joints causing pain. This will also contribute to the tightness. Performing stability exercises will decrease low back pain and hip tightness.

Which Exercises?

The best exercises to improve stability are marches, bent knee fall out and various planks. The key is to keep the core neutral and tight during the exercises. There are many other stability exercises such as bird-dog and dead bugs. Choose 3-4 of them 3 times a week. Progress to standing functional exercises such as a variation on a chop. You can continue other core strengthening exercises but also include spine stability exercises.

Go ahead, stretch and roll out your hip flexors. It will help to manage your symptoms. But, if you find yourself constantly rolling and stretching your hip flexor, ask yourself, how is your core stability.  In order to resolve the tightness, you have to stabilize the spine by improving the endurance of the stability muscles.
* Pictures from

Friday, January 29, 2016

Glutes - How to Transition From Exercise to Run

You've been told you have weak glutes. Whether it's hip pain, knee pain, ankle pain, it all can be "healed" by improving glute strength. You are prescribed clams, side lying leg lifts, bridges then progressed to squats and lunges. You feel stronger and released to go for a run. Your symptoms feel better but returns after getting back to your routine.

Recruiting Glutes vs. Quads

Is your strength transferring from a basic clam exercise to running? Are your glutes REALLY activating when you run? For most of us, we are very quad dominant. This means we over use our quadriceps when we should be using other muscles such as our glutes. Our sedentary lifestyle of sitting at work or relaxing on the couch has us disengaging our glutes. The quads have at a mechanical advantage to work. Also, the habitual use of quadriceps enhances the neural input from the brain is going to the quads and not the glutes. In other words, the wiring to the quads is better then wiring to the glutes. When running, demand on the muscles is so high we use whatever muscles are the easiest to recruit. The Quads.

I have seen and used different cues such as "stick out your butt"or"squeeze your butt as you stand up". However, most of my patients and clients have a difficulty "feeling the exercise". AND, the improved strength doesn't seem to translate to running.


I have been using a different cue to activate the glutes while performing standing exercises such as squats and lunges. While you are performing squats or lunges (or any standing hip exercises i.e. box step ups), pretend like there is an object behind your knee and push back as you stand up. The gluteus maximus is responsible for hip extension, getting your thigh behind you body. However when your foot is fixed on the ground and the knee is given the cue to push back, this extends the knee AND hip. This will engage your gluteus maximus.

Stand up and perform a squat. When you stand up, you feel your thighs press down into the ground and push up. Now try a squat but give the cue for your knees to push back.

FEEL the burn in your glutes.

Now, think of this cue when running. You want to let your knee land normally (with a soft bend), then push back with the knee as your body is moving over your leg. You should feel like your legs are moving in a circle, almost like pedaling a bike. At first, I recommend incorporating this during a warming up, then into sides and finally into your short normal runs. The best way to feel this is up hill sprints!

So on top of performing clams, leg lifts and squats add this "push your knee back" cue to the standing exercises.

Please contact me if you have any questions or concerns.

Thursday, January 21, 2016

Core: More then Abs and Glutes

As athletes, we spend a lot of time working on our core. We plank. We do sit-ups. We twist. However, there is one muscle which is ignored by most athletes that is use in every stride.  In order to run, swim, bike, you need to breathe. The muscle responsible for breathing is the diaphragm. As you pick up the pace, your breathing increases. Your diaphragm is working hard!

What is the Diaphragm?

The diaphragm is a thin muscle that separates the abdominal cavity from the chest cavity. When it is relaxed it rest up against the chest cavity. When we breath the diaphragm contracts and pulls the chest cavity down. This provides negative pressure in the chest cavity allowing air into the lungs. Typically, the core is just seen as the abdominals and back. The core as a box. The pelvic floor muscles on the bottom, abs and back form the side and the diaphragm is the top.

Photo credit -

How Does It Affect my Running?

One of the biggest difficulties I see in the clinic is the inability to separate the diaphragm from the core while breathing. When most of us tighten our core, we stop breathing. OR we continue to breath without tightening our core. We have to learn how to disassociate our diaphragm from our core similar to not using your hamstring when firing your glutes. When we are not able to keep our core tight while we running we lose core stability. This will set off a whole cascade of events which can impact the mechanics of our arms and legs.

The diaphragm has multiple attachments including the hip flexors. This is important because most of us have tightness in our hip flexors. Tightness of hip flexors will not allow the diaphragm relax in  resting state. This tightness will limit our ability to take advantage of a full breath. This forces us to take shallow breaths. This can also contribute to the inability to take a full stride. When the leg is trailing behind, the hip flexor is on maximal stretch. A tight hip flexor will pull on the diaphragm limiting full exhalation.

Lastly, and most important, the diaphragm controls our breathing!

Inability to contract our abdominal muscles separate from the diaphragm and tight hips limit our ability to take full breath. Like any muscle the diaphragm can be stretched and strengthened. On top of stretching the hip flexors and strengthening our core we should also work on improving the use of our diaphragm.

Bonus Info

Side Cramps

A side cramp is when the diaphragm spasms. If you have a cramp on the right, exhale when when your left foot hits the ground. This provides a quick stretch to the diaphragm which helps alleviate symptoms. If your cramp is on your left, exhale as your right foot hits the ground

Finding balance

The diaphragm is also connected to the parasympathetic nervous symptom. This is the "rest and digest" system which allows you to relax. Everyone is busy and on the go which stimulates the sympathetic nervous symptom which is your "fight or fight" symptom. Certain chemicals are released when the sympathetic nervous symptom is activated which, over time, can be detrimental. By diaphragmatic breathing, the parasympathetic nervous system is activated balancing the sympathetic response. If I can't sleep, I focus diaphragmatic breathing and I usually fall asleep within minutes!


Diaphragmatic Breathing

On your back with knees bent, inhale allowing the abdominal cavity to rise then the chest follows. A sign the diaphragm is under-utilized is when the chest and shoulders rise first. To make this more difficult stack a couple of books on your abdominals. Do this for 10 breaths.

This can also be performed in various positions such as sitting, standing or laying down. Eventually diaphragmatic breathing should be natural.

Diaphragmatic Breathing in 3 D

We will work the diaphragm using the lunge matrix.

Stand tall and inhale, as you lunge forward exhale as you bring both arms up. Return to standing and repeat. In the frontal plane, inhale in standing then exhale as you bringing both arms up and to the side. Lastly in the transverse plane, inhale then exhale as you pivot lunge bringing both arms toward the knee.
This exercise provides an additional cue when performing lunges. If you're already doing lunges add the breathing to your routine. You don't have to perform more diaphragmatic lunges.
Perform about 5 repetitions to each side.

*** Side note I have difficulty performing frontal plane breathing exercises. Those who know me know that I had an injury to that side. This is an exercise I will be re-evaluating in a month!