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. 

Hamstring Strain

A nagging pain develops in the back of your thigh. Was it the added speed work? Maybe the increased milage? Could it be a strained hamstring?
Conventional thought is the hamstring bends the knee. When we want to flex the hamstring our knee bends. However, during function, our muscles work differently. In running, the hamstring slows down knee extension as your knee swings forward. The hamstring muscle elongates to control the knee's motion. This is called eccentric muscle action which puts more stress on the muscle. With increase mileage or speed the hamstring becomes overworked and leads to a strain.

Before we look at hamstring, we have to assess other body regions.

Rule Out These Body Regions...

Low Back

The first thing is to rule out referred pain from the lumbar spine. When the nerves of the low back are compressed, it can refer pain to the muscles it innervates. Typically compression of the S1 nerve (also L5 in a smaller population) will refer back to the back of the leg.  Even though the pain is in the hamstring, treating it will not affect the underlying cause. The compression can be caused by a herniated disc or by a condition called stenosis. Taking pressure off the nerve is the only way to treat the "hamstring pain".

Sacroiliac Joint

Next check to make sure the pelvis is level! The pelvis can become malaligned with a mis-step off a curb, long periods of poor posture or simply imbalance of muscles. The hamstring is attached to the ischial tuberosity on the pelvis.  A mis-alignment of the pelvis will have a different pull on the hamstring causing a strain. To perform a quick screen, stand in front of a mirror making sure your feet are aligned forward. Put your hands on your pelvis with the index fingers under the pelvic bone. Look in the mirror to make sure your hands are level.

Top picture: shows level position of pelvis. Bottom picture: shows
rotated position of pelvis

***If you have symptoms of low back or sacroiliac dysfunction please go see your physical therapist.

Hamstring vs Gluteals

When the low back and sacroilliac joint are cleared, we can truly treat the hamstring. OR can we? Conventional treatment is to stretch and strengthen a strained hamstring but research shows the muscle is flexible and strong. Assuming there wasn't a specific incident, a strain muscle signifies overuse. So we have to find out how the hamstring get strained in the first place.
When we look at the function of the hamstring it is similar function of the gluteals. If the gluteals are weak, the hamstrings are at a biomechanical advantage to take over. In addition to treating the hamstring we have to consider glute strength.

Gluteal strength Test 

A quick screen for gluteal strength: Perform 10 on each side. Is there one side that's harder then the other?

Gluteus Medius - Lay on your completely on your side. Leg should be in line with the trunk. Lift leg towards ceiling. ** Make sure to not let the leg drift forward

Gluteus Maximus - Stand in front of a desk and lean forward. Kick your leg back without twisting your hip.

Functional 

Single leg squat - Stand on one leg and perform a squat. Keep the knee aligned forward and pelvic level. 

Left shows good single leg squat form; R shows the knee rolling
inward and and the hip dropping

Basic Strengthening

Clam - Lay on your side with knees bent to about 90 degrees and heel lined with bottom. Keeping the feet together lift knee towards ceiling. The key to this exercise is to ensure the hips are stacked directly on top.

Side leg lift - On your side, hips stacked on top. The bottom leg can be bent for stability. Lift top leg up towards ceiling. Make sure the thigh is in line with the body. The tendency is to allow the leg to drift forward.

Bridges - Lay on your back with your knees bent. Flatten your back by tilting pelvis up. Lift the hips off the ground.

Tri-Plane Strengthening

Tri-planar Lunges with Arm Driver

Using lunges are the best way to strengthen the gluteals. Reaching our arms in different directions can isolate certain muscles. This sequence will help increase gluteal strength. Lunge forward while reaching your hands forward. Next lunge forward while reaching the arms sideways away from the front leg.  Lastly turn your arms towards the right leg. 

Lunge with reach towards foot 

Working the hamstring eccentrically is the best way to simulate it's function while running. Step back with one leg and squat back while keeping the front leg straight.

Treating the Hamstring

Hamstring Stretch 

The first couple days of the onset of hamstring pain, the focus is to decrease inflammation. Apply ice for 15 minutes 2-3 times a day to decrease inflammation and take a couple of days off from running.  After 3-5 days use a heat pack to help increase blood flow to the area. Gentle stretching of the hamstring can start.

Lacrosse Ball Massage

Using a lacrosse ball to massage the hamstrings will help restore mobility of the soft tissue. Providing compression and relaxation to the hamstring will allow improve fluid dynamics of the soft tissue allowing the muscle fibers to glide more efficiently. 

A hamstring strain can take up to several months to resolve. However, taking time off from running and performing the proper exercises can accelerate recovery. Be patient!

Stay tuned for the next post!

It's Plantar Fasciitis!

You get out of bed one morning and your foot hits the ground. "OUCH!" What's causing this pain? You walk around getting ready for work and the pain seems to be disappearing. "Phew", you have to go for your 10 miler after work. The next day the same thing happens. Eventually, you feel the pain every time you stand. AND even when you are running! Finally, after a week you decided to do a Google search - plantar faciitis.
You roll, you ice, you wear a sock thing at night, but nothing changes.

What is plantar fasciitis?

Plantar Fascitis is the inflammation of the fascia (connective tissue) on the bottom of your foot. It spans from the heel to the toes. At the beginning stages,  the tissue gets stretched with weight bearing however over time, with each step the tissue gets more inflamed.

What are the risk factors plantar fasciitis?

A systematic review of journal articles on plantar fasciitis was performed in 2008 and revised in 2014. The big risk factors for getting plantar fasciitis are being a runner, a person who stands for work and limited ankle dorsiflexion. We all all know you're not going to stop running or working, so let's focus on what we can change.

Limited ankle dorsiflexion
This means the ankle joint has a limited mobility to flex the foot towards the body. Ankle dorsiflexion is required to have proper mechanics while running. When ankle dorsiflexion is limited, the sequence of movement of the foot is changed, putting more stress onto the plantar fascia.
Tightness of the calf muscles ( gastrocnemius and soleus) can also contribute to limited dorsiflexion. Connective tissue from the calf spans down into the heel and blends into the plantar fascia. Limited mobility of the calf muscles can contribute to increase stress of the plantar fascia.

Treatment

Ball Roll on Calf 

Most people with plantar fasciitis know to roll the bottom of their foot on a tennis ball or golf ball. However, there is a myofascial pain referral zone at the base of the calf where the muscle becomes tendon. This zone is slightly to the outside of the center of the muscle tendon junction. In a long sit position, use a roller or a lacrosse ball to roll out the area for 2-5 minutes depending on tolerance.

'X' marks the spot

Ankle Mobilization

Lace Lock method

When you can't have a therapist to follow you around, you have to improvise. Using a running shoe is the perfect substitute to assist in self mobilizations. Tie shoes using the lace lock method. Thread the lace on the same side through the last hole. Pull the opposite lace through the hoop. Tie the shoes really tight across the front of the ankle. In standing, put one foot in front and rock forward allowing the knee to bend to mobilize the ankle. Angle the knee to go over the pinky toe. Then angle the one to go over the big toe.
5 times each direction
*** Only tie the shoes laces very tight when mobilizing!!

Calf Stretch with Tri- Plane Tweak

This is a tri-planar tweak on the standard calf stretch. Stand with one foot forward and use knee to drive the motion forward. Then twist left and right. Lastly sway your hips side to side.
Perform 10-15 repetitions

Out of the box

In normal mechanics, the hip and thoracic spine absorbs lateral and rotation motion respectively as the arms swing back and forth. However, if those regions are stiff, the motion is transferred to the ankle. The ankle is forced into an over supinated position. In the supinated position the foot is unable to absorb shock putting more stress on the plantar fascia. Improving mobility in the hips and thoracic spine will take the stress off the plantar fascia.
Please refer to earlier post on stretching the hip and thoracic spine.

http://3drunner.blogspot.com/2015/03/spine-stiffness.html
http://3drunner.blogspot.com/2014/06/ankle-sprain-how-thoracic-spine-and-hip.html

By addressing limitations locally in the ankle and globally at the hip and thoracic spine, you achieve a more comprehensive treatment plan.

3D Exercises - Rotational Opposite Arm Driver

In our 3 stances, squat, lunge and single leg, we can use our arms to create different movements. This changes the exercise by putting an emphasis on varying muscles.

The focus of this series is to use our arms to drive rotation at shoulder level.  These exercises develop the muscles of the upper back and rotator cuff. Not only are these exercises great for all athletes, they specifically strengthen the muscles responsible for controlling the follow-through phase of throwing and hitting.

3D EXERCISES

Discus Squat 

Hold a weight in one hand. As you squat, bring the arm out to the side with the thumb up. As you stand, swing arm across the body using the other hand to stop the weight. Repeat then switch sides.

Lunge Matrix 

Holding a dumb bell in each hand lunge forward and take opposite arm across the body toward the knee. Return to the start position. Repeat on the other side.
Side lunge as you bring the opposite arm towards the knee. Return to start position and repeat on the other side. Rotation lunge as you bring the opposite arm toward bent knee. Repeat to start position and repeat on the other side.

Single Leg Balance ( tri-plane arm drive) 

Standing on one leg with weights in each hand, bring hands to shoulders. Reach arms up in front, back to shoulder. Reach behind your head, back to shoulder. Reach to overhead to the side, back to shoulder. Repeat on the side. Turn arms to one side, back to shoulder. Repeat to the other side.

For each exercise perform 10 repetitions and up to 3 sets

CORE EXERCISE

Bird Dog (aka quadruped arms and legs) 

Kneel in hands and knee position. While keeping a flat back, straighten opposite arm and leg. Keep the pelvis level as you hold the exercise. Maintain a flat back and level pelvis as you bring your arm and leg back into start position.

Hold for 10 seconds perform 10 times.