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.

Core

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.

References

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.

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.

TO BE CLEAR
*** 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.

Tips

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.

Conclusion

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.

"PEOPLE RUN TO GET FIT BUT YOU HAVE TO BE FIT TO RUN" - Chris Powers, PhD, PT, FACSM, FAPTA

STAY TUNED FOR MY NEXT POST ON STRENGTH EXERCISES AND DRILLS TO SAFELY BEGIN FOREFOOT RUNNING



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References

Altman, A.R.  Davis, I.R. Barefoot Running: Biomechanics and Implications for Running Injuries. Current Sports Medicine Reports. Am. J. Sports Med. Volume 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.

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 www.studyblue.com

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.

PUSH YOUR KNEES BACK

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!
THIS CUE WORKS BEST IF YOU MIDFOOT OR FOREFOOT STRIKE!

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.

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 - http://deansomerset.com/core-training-
made-incredibly-complex/

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!

Exercises

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!

Shoulder Pain in Overhead Athletes and Hip Tightness

Although my main focus is injury prevention for runners, I want to address an area of concern I see in the clinic with overhead athletes (athletes who have to bring their arm above their head). Shoulder and elbow injuries are very common in overhead athletes such as baseball players and volleyball players. Rehab typically focuses on the injured shoulder or elbow. However, for a complete recovery, assessment of the whole body must be performed. Otherwise, the injury will linger or affect another body region.

Example 1

Patient presented difficulty lifting his left arm to his ear after a work injury. We focused on his shoulder but the last bit of motion remained painful and limited. I noticed his right leg position rested outward when he was lying on his back. As a result, I decided to take action on his hip mobility. I stretched and mobilized his hip to allow for more neutral position. After 5 minutes of stretching and mobilizing, he had full pain free shoulder motion.

Shows foot pointed outward
as a result of tight hips

Picture shows fascial connections between the
 hip/pelvis and the shoulder girdle
Picture from Born to Walk: Myofascial
Efficiency and the Body in Movement
by James Earls

Why?

Our body is held together by connective tissue which connects our muscles so our body can work together as a system. Tight hip flexors will stiffen the anterior aspect of the trunk and turn the leg outward. This tightness will increase the tension when lifting the arm overhead.

Try This: Raise your right arm overhead and take notice of how your shoulder feels. Now, with the left hand grab and hold the bottom corner of your shirt in your hand. How does it feel? It should feel harder to lift your arm.

Hip Flexor Stretch

Adding arm movements to your stretches allows you to capture the 3 planes of motion, target different angles of the muscles, and ultimately provides a more comprehensive stretch. After the stretch, I recommend performing high knee marches at different angles to activate the newly stretched muscle tissue.

Example 2

A baseball player has shoulder pain only when he pitches. Standard treatment would address his tendonitis. After checking his hip rotation in a standing position, he has limited external rotation of his right hip. Performing joint mobilizations to provide more external rotation eliminates his shoulder pain while throwing.

Pitching Mechanics 

The top video shows pitching mechanics with a throwing warm up but before hip flexor stretching. The bottom video shows pitching mechanics with a throwing warm up and hip flexor stretching. Notice the difference in mechanics. The bottom video shows improved hip opening, shoulder position upon release, and improve knee flexion during the follow through.

Why?

Proper throwing mechanics require the right hip to rotate throughout the movement. When this motion is limited,  the trunk stops rotating and the shoulder has to absorb the energy.

To loosen the hips to prepare for pitching, I recommend hip flexor stretches in all 3 planes. As a follow up, perform a lunge matrix focusing on the rotational lunge.

Bottom Line

These examples demonstrate how the hip can affect the shoulder in everyday tasks and in overhead athletes. The body is connected and works as a system. We need to find the source of the problem and not just treat symptom.

Knee Pain: The Adductors Role

It's the last several weeks before the big marathon. You're out for your 20 mile run and feel great. BAM at mile 11, an ache develops at the side of the knee. You try to ignore it. You try to run it off. But it gets worse. You have to do the walk of shame home.
A basic Google search brings up ITB tendonitis. You foam roll your ITB, you ICE and you do glute strengthening. Your knee pain is slightly better but is still nagging. What is causing this continue?

A running analysis reveals something unexpected.



The left leg lands under the center of the body. However, the injured leg drifts towards OVER the center of the body when it hits the ground. Each time the foot lands the ITB is getting injured.

What can cause this?

Adductor mobility

Adductor muscle group. Thieme: Atlas of Anatomy General Anatomy and Musculoskeletal System

Left: normal running position Right: Tightness of the left adductor
bringing the right leg closer to midline as it lands.

A closer look at her adductors revealed the UNINJURED leg lacks 15 degrees of mobility. The trail leg extends behind the body AND is stretched sideways from the body. Lack of mobility of the adductors of the trail leg pulls the front leg laterally. When the leg hits the ground it lands under the center of the body. This will put a stretch stress to the lateral side of the leg. The connective tissue of the out side of the leg gets over stretched causing ITB tendonitis.

Adductor Stretch

Place one foot up onto bench with foot turned away with the knee bent. Shift body weight towards the bent knee to feel stretch on the inner thigh. Drive hip forward and backwards, side to side and twist. 

                        

Follow up the stretch with a tri-plane lunge. This will help keep the adductors strong and mobile.  http://3drunner.blogspot.com/2015/07/basics-of-3d-exercises.html

The next time your ITB flares up, take a look at your adductor mobility.