How to prevent running injuries PART 2

Oct 11, 2022 | by Elise Mulvihill

Running assessment and clinical case study  

Using video to analyse a client’s running on treadmill helps us to identify running types, as well as potential abnormalities that may be contributing to injuries, writes physiotherapist Elise Mulvihill.

You can read Part 1 of this series here.

With ever greater numbers of people participating in recreational as well as competetive running, it’s highly likely that you will have clients who regularly pound the pavement. With this increased participation comes increased incidence of injury. This is where a treadmill running assessment comes into play.

A running assessment is made up of video analysis of a client running on a treadmill, in conjunction with other clinical testing such as range of movement (ROM) and strength, as well as ongoing subjective assessments to gauge things like running load, which has particular relevance in instances of overuse injuries.

Utilising video analysis on the treadmill to review joint kinematics helps us to identify running types, as well as potential abnormalities that may be contributing to injuries. These irregularities may then be further assessed, and interventions planned for injury management.

Treadmill analysis and combination hypothesis

Treadmill running has been shown to demonstrate significantly similar joint kinematics to overground running, making it a useful and convenient tool for analysing movement.

A combination of factors can lead us to a hypothesis as to why a client may be getting injured while running

The type of analysis we do requires at least two views that intersect one another – i.e. rear and side. The treadmill enables us to recreate the variables to make the environment as close to onset of symptoms as possible, specifically the velocity at which your client usually runs, and the time frame of the onset of symptoms.

The key point with treadmill analysis is that none of these factors in isolation lead to one particular diagnosis or injury, but a combination of such factors can lead us to a hypothesis as to why a client may be getting injured while running.

Clinical case study

In these video freeze-frame pictures, we are using a clinical case study of our patient Liam, who we have analysed using the below framework to put things into action. In the workshop seminar (click here to view free seminar videos) you can see the video in real time, and watch him progress through his usual running gait pattern. In this presentation, we utilise the slower frames to start making our way through the check list – starting at the toes and heading up towards the nose.

  1. Side view
A person running on a treadmill

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In the side view we look at a number of body movements. At initial foot strike, we look to see if the client is a heel striker, mid foot striker or forefoot striker. The foot inclination angle is the angle created by the sole of the foot and the belt of the treadmill. Greater angles here have been shown to be directly related to larger ground reaction forces. Further up the shin is the tibia angle at loading. This should be as vertical as possible. As you can see, from this angle Liam looks pretty normal. He also has a nice mid foot landing and nice vertical tibia, so he ticks the boxes here well.

At the knee, we look at flexion angle during stance, from initial contact through to maximum angle which is reflective of shock absorption capacities. Again, Liam is doing well with adequate knee flexion. We then look at extension during late stance, trunk lean, overstriding and the vertical displacement of centre of mass (upward displacement). Liam does have slightly too much vertical displacement, but he has adequate hip extension, and together this gives the impression that he is not overstriding.

  1. Rear view
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Looking at the rear view, we start to find some interesting things in a lot of patients, and especially in Liam. The general rule with the ‘base of support’ (your feet) is that the left and the right foot should not overlap in their ground contact location. With heel eversion, we look at the angles of pronation as well as how quickly it occurs. Looking at his base of support, we can immediately see that Liam is demonstrating a ‘crossover sign’, meaning his feet are crossing the midline.

He does, however, get one green tick in this view, and that is his foot progression angle which

seems to be OK when we view the slowed down video. The foot progression angle is the relationship between the heel and the toe in a transverse plane. Changes to this mean we could investigate things like hip internal rotation, knee internal rotation, or some combination of these for a toe in gait (as opposed to a toe out gait).

As we continue moving through the body, from feet to head, we can see that his left ‘heel whip’ is greater than his right side. The ‘heel whip’ is an outward movement of the foot and is measured by comparing the angle of the plantar surface of the shoe at initial contact with the plantar surface at the point of maximum rotation.

The ‘knee window’ is the evaluation of the presence, or the absence, of space between the knees at all times. Things that can cause a reduced knee window include excessive hip internal rotation, hip adduction and knee valgus. Liam demonstrates a ‘closed’ knee window, with his knees too close together.

Lastly, we take note of the pelvic drop. This is assessed during the stance phase, and compares the level of the pelvis on both sides. Excessive pelvic drop contributes to excessive hip adduction, which is a factor linked to running injuries. Pelvic drop during running has been shown to be related to both hip abductor strength and hip extension strength: fatiguing of these muscles results in excessive drop. This is significant in Liam’s case, with both pelvic drop and excessive trunk rotation in evidence.

The other thing of note in Liam’s case is his lack of mobility of his left scapular, or arm. From taking a thorough injury history, we know that he has experienced a previous shoulder injury which may be causing the lack of movement. As we piece together his mechanics, we can see that through the chain he is compensating for this lack of movement with a significant increase in rotation around his back and then, following this, a pelvic drop. Such variations in his gait could be correlated with things like weak glutes or poor core stability. This is highly relative in this case, as Liam has been

known to have issues with his pelvic floor, and recurring episodes of back pain.

  1. Front view
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Although the majority of information is taken from the side and rear views, in our assessments we also look at the front view as it gives us a clear indication of knee angle and rotation, as well as further confirmation of the biomechanics at the base of support.

So, once we have considered the observations gained from the treadmill running assessment, the next step in the case of a symptomatic individual like Liam is to determine how to intervene and prevent ongoing back pain so that he can continue running.

CLICK HERE to read How to prevent running injuries – PART 3: Good running form and strength and mobility exercises


Elise Mulvihill

Elise Mulvihill

Elise is a Senior Physiotherapist at Physio Fitness, Bondi Junction. She has worked in sports physiotherapy clinics with a variety of both recreational and high level athletes and teams, competing in sports such as rugby league, soccer, basketball and touch football. With a passion for health and movement, Elise appreciates the importance of exercise in her clients’ recovery, return to sports, and prevention of injury recurrence. She also instructs group mat Pilates And 1:1 reformer training. To watch the full workshop presentation on running injuries, or to discuss referring your clients to Physio Fitness, visit physiofitness.com.physiofitness.com.au/running-assessments

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