Calf pain in runners: 9 causes and considerations From footwear to form

One of the most common complaints runners have is calf pain, particularly while running. It might initially come in bouts during just a couple runs, but sometimes it will stick around for weeks and months if left unaddressed. Rest usually improves this discomfort at first, but isn’t typically sufficient for long-term, consistent relief if the person continues to run and doesn’t make any other changes. They’ll complain that their calf muscles feel “tight.” And it’s common for both calf muscle groups to start to feel this way around the same time.

Some runners take the “I give up” approach and assume it’s a necessary part of getting older or running too many miles, so they begin to modify their training around it by planning an additional rest day or cross training instead. They take the “a little running is better than no running” approach, which I think is very reasonable for a true injury, but when something can be improved, why not address it the right way?

For the sake of this article let’s assume we are covering muscle-specific pain in the calf that isn’t too bothersome much outside of running. These are more likely to be muscle overuse syndromes or biomechanical overload syndromes. This cause of pain can be treated while you continue to run, if done correctly.

But there are plenty of other things that can cause calf pain and you will need a medical professional, not an internet article, to rule those out.

Possible (and Potentially Serious) Medical Issues to Rule Out

• Blood clots/deep vein thrombosis

• Nerve mobility deficits or irritability of the lumbar, sciatic, and tibial nerves

• Calf muscle tear/rupture

• Popliteal artery entrapment

What can you do?

Seek professional medical guidance if you have had a traumatic injury (often accompanied by a sudden “pop” or a feeling of being kicked in the calf). We are also very concerned if there is a more persistent or severe onset of pain, or additional symptoms like sensation changes (pins, needles, tingling, burning), fever, swelling, and redness of the calf. It’s important to consider your overall history because factors such as being older, having a history of a particular problem, recent immobilization, comorbidities, and certain medications can all have a role. These issues are very different than a mild discomfort, tightness, or fatigue that occurs only while running. It isn’t to say that some of these problems can’t be treated conservatively but you will have the best chance at success with proper diagnosis. We need to keep in mind too, if you have attempted treatment that doesn’t seem to be helping.

Other considerations:

Calf Strength and Endurance Deficits

Logic would tell you that running demands a ton of work from the leg muscles. At some routine level of activity, the muscles adapt to that work and you keep on going from week to week without issues, just as happily as ever. Now what happens if you chronically demand so much from those muscles that they can’t adapt to what you are trying to have them do? They slowly start to...change…like your best friend from junior high school. At first it was cute but two months later you were just annoyed. The muscles don’t have to be painful, at first. Maybe they just feel more tired and tight. But when you keep running on them and don’t make any other changes they become more consistently problematic.

The muscle and fascial connective tissue isn’t able to adapt to your demands in a positive manner when demand outpaces normal repair over a long period of time. Why couldn’t the muscles withstand the demand? Most likely there wasn’t enough strength or endurance (or both) in the muscle group. Given enough time of chronic repetitive stress on under-prepared tissue, the quality of the soft tissue changes.

Running really requires something called “strength endurance” from muscles like the calf. You might even better call it “strength and power endurance,” but I don’t want the top of your head to blow off right now so forget I said that. The point is that the muscles of the calf have to withstand high forces (strength), very rapidly (power), and with high frequency (endurance).

The calf-strength variations that will show up when tested during a single leg calf/heel raise are often interesting. A runner might have tons of gastrocnemius strength during a straight-knee calf raise, but when the calf raise is re-tested while the knee is flexed, they can’t reach the top end of the calf raise anymore. Often this means they have decreased soleus strength, which is a real problem since, while running, we spend a large portion of the running stride with the knee slightly bent. Or maybe they can’t perform the same amount of reps on one side when compared to the other in either position.

Even worse is when the person can’t perform any type of single leg calf raises without relying on their long toe flexing muscles that come from deep in the calf region. My heart hurts when I see this. These people tend to grip with their toes during calf raises and just can’t get their brain to shut those muscles off while completing the raise because the bigger, outer calf muscles are just that weak. It’s not a surprise that people will run with those toe muscles engaged heavily too.

What can you do?

Build the strength of the calf muscles using calf raises, with the knee slightly bent and straight, without gripping with the toes, and with just a single leg at a time. Full ankle range of motion is key. Causing calf muscle fatigue is the goal. That might take five reps or 20. Don’t hammer it to death because you’ll probably become sore for two days. Early strengthening with bodyweight is good but after 2-3 weeks of 3-4x/week, runners should be able to add extra resistance, even beginning with something like 10 pounds. The calf needs to be strong, but...

Other Strength Deficits

I am stating the obvious here, but it takes more than the calf muscles to propel a runner. Lacking hip or thigh strength could lead to a trickle-down of abnormal demand into the calf muscles. The calf could actually be super strong but just have to endure too much stress every time you go running because something else stinks at its job. End result: too much work being done by the calf muscles that leads to stress-induced discomfort.

What can you do?

Ensure you have full strength of the hip and thigh muscles (eg. gluteus maximus, gluteus medius, hamstrings, quadriceps). Strengthening exercises for these areas is beyond the scope of this article, but the point is you need to look outside the area of symptoms if you want to actually fix the problem. Remember to emphasize single-leg strengthening to ensure symmetry. If you can only do eight single leg bridges on one side and 20 on the other then you’ve got some extra work to do on the weaker side.

Neuromuscular control

Your awareness of and ability to modify the way your body moves at any given instant is a good indicator of overall athleticism. Remember, our muscles only know how to function based on what they are told by the nervous system, particularly the spinal cord. If your nervous system can’t figure out how much force to generate from the various muscles at any one moment then your movement isn’t refined. Picture a gymnast on a balance beam. It doesn’t take much error to result in falling off the beam. They really have to own their movements with precision and certainty. Kinda, sorta knowing where their feet are isn’t going to cut it. Or imagine an infant learning to crawl. They are constantly on the edge of failure until their nervous system figures out the best way to coordinate muscle contractions to keep their body stable. Your calf muscles must contract with correct amounts of other muscle contractions in that leg with every footstrike.

What can you do?

Working on drills to improve your balance and proprioception is key. As previously mentioned, single-leg work is a necessity. And I don’t mean sit on a machine to do knee extensions, calf raises or leg presses one leg at a time. When you use machines, there’s no real demand that requires the nervous system to learn how to stabilize your body. Single leg balance that progresses into single leg deadlifts, single leg squats, single leg hops, single leg box jumps, single leg calf raises, the options are many. The point is to emphasize standing on one leg while you move the rest of your body.

Foot, Ankle Structure

An individual with a more flexible foot or ankle type that allows an inward collapse of the heel bone or inner foot arch could be placing more demand on their calf. These people are generically labeled as “flat-footed.” Though the more superficial calf muscles are mainly producing force for the forward/backward sagittal plane, there are additional forces that this outer calf and much deeper calf must withstand in the side-to-side or frontal plane. And then we must consider that the deeper calf muscles, like the posterior tibialis, that help to control the side-to-side ankle and foot motion, are also notorious for being part of the cause of pain.

What can you do?

Build the strength of the muscles that assist in stabilizing the ankle and foot that also come from the lower leg, like the peroneus longus, peroneus brevis, anterior tibialis, and posterior tibialis. One way of doing this is with resistance bands. This is also why I love single leg strengthening exercises like single leg Russian deadlifts that also require a person to balance and stabilize like a circus elephant on top a ball. As discussed below, you should perform routine soft-tissue maintenance on all of the calf muscles, superficial and deep.

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Maintenance Habits

Here’s a big one. So you run for hours at a time or try to run really fast, essentially beating down the calf muscle fibers and their surrounding fascia and tendons, but then you don’t do anything good for those tissues? Resting is supposed to fix it all? It probably would if you weren’t trying to run most days of the week.

What can you do?

Buy and use a massage stick, foam roller, or lacrosse ball to routinely massage the muscles of the legs. Be sure to emphasize routine soft tissue maintenance for every major muscle group. The technique doesn’t matter as much as just doing something positive regularly for the muscles to keep them more supple and loose. Before the pain rules your life. Once the pain is consistently present, I can use techniques to get it to go away quickly and then you need to take over with a maintenance program.

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Calf Muscle Length

In many instances, you can think of calf muscle length as an indicator of something besides true structural muscle fiber, fascia, or tendon length. The chronic abuse of running very often leads your nervous system into thinking a higher level of nerve-dependent activity is needed in the calf when it really isn’t. That keeps the fibers holding a greater tension at all times, which makes the calf muscle appear shorter than it really is structurally. So there’s a big difference between your nervous system telling a muscle to behave as if it is tight and a muscle that truly, structurally is short and tight. Weird, I know.

What can you do?

Calf stretching with the runner’s stretch or dropping your heel off a step is typically what runners choose to do if their calves feel tight. But if you want a change in actual muscle structure and length, be prepared for it to take multiple weeks of frequent and prolonged stretching. Like three 60-second stretches at least three days per week. A deep full squat will more likely max out the ankle joint motion and soleus muscle length while a straight leg heel drop on a step is meant to be a gastrocnemius stretch. But I would rather rely on the other soft tissue techniques mentioned above as maintenance, like self-massage, myofascial release, or dry needling to make the muscles relax, which automatically improves their length in many people. Remember, the goal probably doesn’t need to be improving the muscle fiber lengths, it’s convincing your nervous system to let the darn muscle relax.

Running Technique

Certain techniques tend to stress certain tissues more over time - that is neither bad nor good. If there were ever a predictable running method to stress the calf muscles, it would be a forefoot initial contact style, particularly if the runner doesn’t allow the heel to reach the ground after making contact. With about 2.5x to 3x your bodyweight coming through the limb while running, there are huge lengthening or eccentric forces coming through the calf tissue when the forefoot touches the ground before any other part of the foot. This could be the case with midfoot striking too. Depending on the runner’s individual style though, midfoot contact can decrease calf stress. Heel striking itself doesn’t necessarily tend to load the calf the same way a forefoot contact might, but rest assured those people have their own set of problems at the knees, thighs, and hips. Overstriding, which commonly accompanies heel striking, can be more stressful though.

What can you do?

By choosing to use a forefoot contact you should know the calf area is at risk for injury and perform your due diligence with the maintenance just mentioned to keep the calf muscles loose, relaxed, and happy! You may not immediately need to modify your technique to a heel or midfoot strike but could do so temporarily to maintain running fitness until the calf muscle status has been improved. Overstriding needs addressed in any instance. This is where we often need to address hip strength and control, hip flexor length, and other possible issues throughout the entire leg.

Paces, Distances, Training Program Design

What type of running have you been doing lately? Fast, slow, mixed speed, uphill, downhill, shorter distance, longer distance? Are these methods what you have always done or has your training changed recently to incorporate more speedwork, racing, or hills?

What can you do?

If you changed your distance, terrain, or speeds, and the changes contributed to the symptoms, temporarily remove or decrease those stressors for a week or two. Uphills and running faster are the most potent instigators of calf pain. Know the threshold of when the pain would begin while running and then try to stay just beneath that point for a couple weeks while the strengthening and other soft tissue treatment take hold. Be sure to have a full recovery day without sports or running that doesn’t stress the calf muscles.

Footwear

So you thought the zero drop or minimal shoes were great choice? Well, they are, but not if all this other stuff is off and you suddenly change the shoes too. They cause at least a 10% increase in calf load compared to a traditional shoe. Add that onto your already lackluster muscle tissue quality and we have a recipe for trouble. This is also an issue for runners when they switch suddenly from their base training shoes into their racing flats or spikes for competition.

What can you do?

Work your way into minimal or zero drop shoes gradually if you haven’t used them before. Two or three runs per week of 5-10 minutes is plenty in the first month. Run your warm up with them and then switch into your old training shoes. Gradually add faster workouts with spikes and flats into your training instead of just competing in those shoes. Spend more time barefoot at home and be sure to do the maintenance piece mentioned above to get the muscle tone to decrease. Here’s a nice article on transitioning to minimal footwear.

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Foot and ankle pain from posterior tibial tendon and muscle injury

Anatomy:

The posterior tibialis muscle originates on the back of the tibia, turns to tendon, and runs behind the bump at the inner ankle (the medial malleolus), and inserts into several of the bones within the arch and underside of the foot.

image courtesy aafp.org

Function:

In a standing position, when the posterior tibialis muscle contracts, the inner arch of the foot tends to rise away from the ground. In walking or running the tendon receives its biggest demand when we arrive at midstance and have all of our weight on that single foot. Some pronation during this moment is great for shock absorption but it should meet an end point. That end point is controlled partly by this muscle. This muscle plays a very important role in controlling the amount and rate of pronation occurring at the midfoot.

Causes:

Because the posterior tibial tendon takes a bend around the back of the tibia, the tendon is subjected to tensioning loads as well as compressive loads. To make matters worse, that area of tendon has a poor blood supply.

As usual, progressing intensity or volume of exercise too rapidly is a common finding in people with pain from the muscle or tendon.

There may be weakness of nearby muscles, like the gastrocnemius or soleus, resulting in greater demand on the posterior tibialis muscle.

Some people will aggravate the posterior tibialis tendon indirectly because they lack full ankle dorsiflexion range of motion. By losing motion at this one joint, the adjacent joints can be placed under additional demand. That stress is then controlled for by greater posterior tibialis muscle and tendon activity.

A change in footwear or foot orthotics could be related to onset as the demand on certain tissues could increase.

Poor balance, stability, and positional control of the hip, knee, and ankle may contribute overuse demands to the tissue.

Some people are predisposed to a more flexible and flat foot structure that will, in turn, place greater forces on the posterior tibialis tendon and muscle.

Other rare cases may have a tendon that wants to pop out of the groove that it is resting within, which is associated with a previous traumatic ankle injury.

Signs and Symptoms:

Pain typically comes on without trauma and is usually directly behind the medial malleoli if the tendon is involved but can be at the calf and bottom of the foot if the symptoms are coming more from the muscle. It is interesting to note that an aggravation of the posterior tibialis muscle can mimic an Achilles tendon pain. Take a look at the muscle referral pattern.

http://www.triggerpoints.net/muscle/tibialis-posterior

Decreased ankle dorsiflexion motion is common. We would measure the joint angle in the clinic, but consider it a bad sign if you can’t squat fully while keeping your heels on the ground or if you can’t lift your toes and forefoot off the ground a couple inches while keeping the shin perpendicular to the floor. Here I have used a ruler as a reference. The ruler maintains its position while I pull the foot toward my shin. Notice the size of the gap between foot and ruler in the second picture. While decreased motion could be from weakness of the anterior tibialis muscle, shortness of the calf muscles is often a contributing problem.

There may be localized tenderness and swelling just behind the medial malleolus. Especially as the condition progresses, you may notice a clicking sensation at the inner ankle region during ankle movement. This could be particularly bothersome if it is simultaneously painful.

When performing a single leg calf raise there can be pain and weakness, especially at the end point of the motion where the heel should be twisting inward a small amount, as in the picture below. You should be able to perform at least 10 repetitions of a single leg calf raise in a row, one set with the knee straight, one set with the knee bent.

Balance and stability should be sufficient enough to maintain a single leg stance with your eyes closed for 30 seconds.

If the destruction of an early tendon injury worsens, the inner arch will flatten as the tendon lengthens abnormally, causing a “flat foot deformity.” This is the reason you really want to catch an injury to the tendon early, before any long-term structural changes have occurred. If the normal structure has been modified then you will have a much longer road to recovery.

Other possible or related problems:

Pain at the inner ankle and lower leg can also be caused by a few other issues. This is where seeing a trained professional helps to rule out these other problems. If you are experiencing severe pain, numbness, tingling, pins and needles, general calf swelling and tightness then definitely don’t try to self-treat.

• Ankle sprain

• Blood clots in the lower leg

• Sciatic nerve compression and irritation

• Lumbar nerve compression and irritation

• Tibial nerve compression and irritation

• Sacroiliac joint alignment/stability problems

• Hip region muscle trigger points/muscle tissue dysfunction

• Flexor digitorum longus tendinopathy/trigger points/muscle tissue dysfunction

• Flexor hallucis longus tendinopathy/trigger points/muscle tissue dysfunction

• Abductor hallucis trigger points/muscle tissue dysfunction

• Loss of hip mobility from decreased muscle flexibility or hip joint problems

• Fracture or stress fracture

• Tarsal tunnel syndrome

Treatment:

General treatment goals are going to consist of some combination of the following:

• Decreasing pain

• Increasing lost motion

• Increasing stability and balance

• Increasing muscle and tendon endurance

• Increasing muscle and tendon strength

• Resolving any abnormal movement patterns

• Preventing recurrence

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Short-term rest, ice, and NSAIDs are generally appropriate in healthy people for immediate care of a new injury to decrease pain. I am always going to emphasize that it is important to determine why the injury occurred in the first place as these methods do nothing to address the real causative factors.

Supporting the arch of the foot during the stance phase of foot strike can be helpful in decreasing load on the posterior tibialis temporarily. This can be achieved with taping, temporary or permanent foot orthotics, and footwear modifications. You should not become reliant upon these devices to keep your deficits at bay forever, though.

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Strengthening the posterior tibialis muscle and tendon can be a beneficial method to increase tissue integrity. The most common strengthening method for a moderately calm tendon is a single leg calf raise performed with the knee straight and the knee bent. If that is too painful, the individual can perform these with double leg support or perform ankle inversion with a cuff weight or band until the calf raise can be performed with moderate or no pain. When strengthening tendon, the current research indicates that it is acceptable to cause mild discomfort in the area of tendon injury but you would not want to push the tendon so far that it remains painful for hours or worsens the following day. In many people holding the topmost portion of the calf raise for 15-30 seconds, known as an isometric, can help decrease pain.

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There is no substitute for having full ankle range of motion. If ankle motion is lost, you may need to work on a combination of stretching, joint mobilization, and other soft tissue work to regain mobility. Soft tissue techniques are of benefit to improve any excess muscle tissue tone and gain length. This includes foam rolling, massage stick rolling, massage, myofascial release, and dry needling.

More aggressive treatment can include the use of a walking boot for immobilization and corticosteroid injections. These injections will coincide with a risk of tendon rupture, however, and should be avoided if possible. Another type of injection is PRP (platelet rich plasma). Some physicians will provide patients with nitroglycerin patches to improve local blood supply to the tendon. Surgical intervention is the last thing you want but may be particularly necessary if the tendon has remained inflamed for such a long period that it cannot glide smoothly in its sheath or has split longitudinally. A newer minimally invasive procedure to help chronic tendon injuries is called Tenex.

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Three common overuse injury mistakes you are making and how to avoid them

Using the “wait and see” method:

There are two ways to go wrong with the “wait and see” method. In the first, an athlete, believing “rest” is the critical factor in injury recovery, takes a large amount of time off after the initial onset of pain. When they do finally return to activity, having had no pain for a day or two, they often start out with way too much intensity or time. If you haven’t run in 2 weeks, then the first run back should not be a 5-mile excursion. In fact, it should be quite brief. And of course, instead of running an easy 10-minute mile pace, your legs are fresh, so 7- or 8-minute miles seem suddenly more comfortable than ever.

Few people ever follow this advice because there is a misconception that rest fixes all. (Same assumption goes for surgery fixing everything, but that’s another story.) And then the athlete can’t figure out why the injury came back a couple weeks later. Of course that recurrence is followed by yet another solid block of rest and the cycle of inconsistency continues. The body WANTS to heal. I find that to be pretty amazing. The key is providing consistent exercise loading to not only maintain fitness but to improve tissue integrity.

Don’t get me wrong. Rest is extremely important in recovery from training and from injury. But it should all be administered in appropriate doses. If you know, deep down, that rest is powerful then you should be doing a better job of resting prior to any symptom onset, not waiting until something hurts. Rest should never be considered as the primary method to address injury.

In the second scenario, the athlete ignores their initial injury symptoms and continues to exercise, waiting for the injury to spontaneously resolve. This can stack too much stress onto an already injured area. It’s often easy to do with running, because so many muscle and tendon injuries actually feel better once the tissues have warmed up a bit. That’s why overuse injuries are so deceiving. If the pain is gone while exercising, you must be doing okay, right? Well, no, it’s not that easy.

If we were to classify the onset of pain from overuse injury, there’s typically a progression:

1. Pain only after exercise.

2. Pain during exercise, though not at a high enough level to stop.

3. Pain during exercise that does limit time or performance.

4. Pain so severe you absolutely cannot exercise.

Athletes often become stuck at the second phase. Sometimes for months at a time. When they approach the third phase, they suddenly become desperate and finally begin addressing the things they knew were problems in the first place. Don’t be “that guy.”

Consider yourself only as good as your last successful, pain free run. Best not to worry about progressing when injured if you want a long career. Best to worry about preventing regression and working on your known problem areas, like hip strength or ankle range of motion. If you don’t know where your problem areas are, seek guidance from a movement expert.

Relying on pills and injections:

Everybody loves a “quick fix.” Some like it because it requires no real effort or time to take a pill. Others like it because it might reliably take pain away and they are unaware of any other treatment option. For some people, they feel they don’t have time for proper injury treatment. In any case, once the pain decreases you expect to go on about your training as soon as possible without any other care.

But think about this for a moment. If a mechanical stress led to your painful tissue damage, then there’s good reason to focus on a mechanical solution when there is one available. Medicines aren’t typically designed to alter mechanical stress. Let’s say the medication did stop the pain. Just because the pain stopped doesn’t mean the underlying problem went away.

Unfortunately, rarely is the proper solution a quick one. Pills and injections are not a reasonable long-term solution. Just like appropriate doses of rest, NSAIDs and corticosteroid injections certainly have a place in treatment. But they are not a valid long-term option for relief of overuse damage.  

Blaming the shoes:

I am guessing the shoe industry is at fault for this perception. It’s not about the shoes. Overuse injuries are likely to be caused by a variety of factors but most frequently by training errors. This means your intensity was too high, distance too long, or the rest was insufficient. (This is the third time I have mentioned rest!)

Even the biomechanical flaws that I might address in the clinic take a back seat to poor program design. We are highly adaptable. Each running technique is known to stress specific tissues.

What might be considered horrible running technique can be safely performed if you progressed slowly enough and were strong in all the right muscles, tendons, and ligaments.

Summary:

Like the cause of the injury, resolution should be a multifactorial approach. The trick is going to be exercising within the tolerances that the injured area allows while also working on any related deficits. Back the distance and pace down.

It’s unreasonable to believe that you don’t have mechanical deficits somewhere that contribute to the injury. Training errors in speed and time just make those flaws more prominent. You must look outside the area of injury. The body relies on an integration of systems for movement so if just one system fails at its job then you have a problem. And that problem probably isn’t where your pain is occurring. Is your balance perfect? Movement awareness stellar? Posture perfect? Strength out of this world? Have the joint motion of a 10 year old? Unlikely. Bring home those new shoes and get to work on the right things.

Strength Training for Runners, Part 3: How?

So hopefully I’m persuading a few runners to try adding strength training to their regimen. Let’s go over some general strength training tips and the primary objectives to consider for the various muscle groups.

Strength training tips and objectives

1. Your primary goal is to place a stress on the body that it isn’t accustomed to and that, in some ways, exceeds the stress that running places on the body. This demand is what leads to positive adaptations.

• Efficient running is stressful for the muscles, tendons, bones, joints, and other tissues in the body.

• Inefficient running is even more stressful on many of these structures, which means you want to either get rid of the inefficiency (ideal) or make your body more tolerant of it (not ideal).

2. The progression should go as follows: mobility → skill → stability → endurance → strength → power

• This means you need to master the basic movement pattern with a full range of motion far before you attempt to move heavy amounts of weight or move explosively.

• Running requires tons of repetitions of a powerful movement yet many people don’t have the basic mobility and strength down to safely use that power.

3. Circuit train, especially if you aren’t accustomed to strength training yet.

• Runners love to stay moving, so your earliest forays into strengthening can emphasize circuit training of the entire body. Circuit training allows you to move right from one exercise into another, bringing the heart rate up and providing a similar feel to the constant work of running that we crave.

• Circuit training is more reasonable from a time-management perspective.

• If you are new to strength work, alternate upper body, lower body, and core exercises to let each muscle region recover effectively in between exercises.

• More experienced athletes can stack a single set of two or three similar exercises together to increase the muscle demand. For example, lunges followed by single leg squats and then on to step-ups.

• You can add plyometric and agility drills throughout the strength session to keep the heart rate up and integrate running with speed, which is discussed next.

4. Integrate strengthening into your run workouts to improve your awareness of how to use those muscles while running.

• Going back to circuit training, here’s one of my favorite winter activities when the weather is horrible and I must run inside:

  • Treadmill run 5 minutes

  • Hip strengthening and stability 1-2 minutes

  • Core strengthening and stability 1-2 minutes

  • Leg strengthening 1-2 minutes

  • Wash, rinse, and repeat for 45 to 90 minutes total

• Perform a couple of bodyweight resisted exercises like leg raises or planks during your warm up to emphasize core and hip stability, strengthening, posture correction, and muscle awareness.

5. The abdominals (and actually some hip muscles) are primarily stabilizers when you run so learn to use them in that way.

• Instead of crunches or sit-ups, use variations of planks and bridges.

• Emphasize single leg activities with the pelvis held in a level position. I reviewed the pelvic position last week with the Trendelenburg's sign.

6. Work one side of the body at a time.

• Symmetry in muscle strength is a key point. Working both sides of the body at the same time is less challenging and less productive because you will inevitably use a more dominant side without even realizing it.

7. Work multiple muscle groups simultaneously by emphasizing “closed chain” movements.

• Closed chain implies the end of the leg or arm will be in contact with the ground or fixed object. Examples include squats, lunges, push-ups, step-ups, power cleans, planks, pull-ups, and most plyometrics like jumping and hopping.

• Closed chain movements mimic running and normal daily activity. Open chain exercises, like leg extensions, do not often duplicate our day-to-day movement.

8. Think about performing exercises by the plane of movement that you move each joint through and then do a little work for each plane.

• Squats and lunges emphasize a forward/backward plane at the knees and hips.

• Single leg hip rotations emphasize a horizontal plane at the hips.

• Pelvic drops emphasize a side-to-side plane at the hips and trunk.

9. When an exercise has become too easy, add an element to decrease stability and see if that doesn’t increase the difficulty.

• For example, a standard front plank is easily advanced by lifting one leg, one arm, or both at the same time. The idea is to increase the wobble factor.

• Some equipment options to increase instability include swiss balls, BOSU balls, and wobble boards.

• Many standing exercises can be performed on a single leg to challenge the stability but you need to be proficient with their double-legged versions first.

10. Avoid using machines, emphasize free weights.

• The limited range of motion keeps you from working in the positions that you actually need to gain usable strength.

• Machines do not challenge the stabilizing muscles and nervous system components that can be beneficial for injury prevention and optimal performance.

• Free weights are more likely to mimic the tasks that we perform in daily life because we commonly lift and move heavy objects.

11. Reduce strength training loads primarily in the week before your “A” races but not before “B” or “C” races.

• Strengthening is part of the constant stimulus that you are trying to adapt to, so you don’t want to recover excessively before your low priority events. Train on through.

• While training just before a low priority event you can decrease the number of repetitions in a set by 3-5 but keep the weight the same.

• Before an “A” race, decrease both the sets, resistance, and repetitions if you have been working with resistances that cause failure at higher repetitions (i.e., do only 1-2 sets of 15-30 repetitions instead of 2-3 sets of 15-40 repetitions). If you have been gearing up with really high loads and performing more powerful, explosive moves, then back the sets down and the resistance only slightly (ie. do 2-5 sets of 3-8 repetitions instead of 5-6 sets of 3-8 repetitions).

12. Once your priority event has passed, back off of the rapid power and agility movements and encourage basic strength and strength endurance again for 2-4 weeks.

13. Perform strength training on shorter or less intense running days, especially if you have never strength trained before.

• We don’t need too much of a good thing. Too much exercise stimuli in a day or series of days is a recipe for injury.

• I often still use running as a brief warm-up before strengthening and, as mentioned, incorporate running drills throughout the strength workout.

• Strength days are a great time to do other cross training on a bike, elliptical, rower, rock wall, or anything that allows you to experiment and break up the monotony of running.

14. A general initial strengthening structure could consider spending:

• 50% of the time on the large primary movement muscle groups that undergo heavy use in running to improve overall movement strength and strength endurance.

  • These muscles, like the quadriceps, gluteus maximus, and hamstrings, can be pushed harder with higher resistances.

• 25% of your time focusing on the muscle groups that are not dominant and become neglected in the running motion to prevent injury.

  • These muscles, like the deep gluteals, usually require very little resistance because they are not large or power producing.

• 25% of the time integrating plyometric drills to increase power output, speed, and agility.

15. Allow at least 6-8 weeks of working at least 1x/week for noticeable performance changes.

In next week's blog I'll go over more application specifics and exercises. 

Please let me know if you have any questions at derek@mountainridgept.com. If you enjoy reading these articles and applying them to your training, please “like” the Mountain Ridge Physical Therapy Facebook page.

Balance and proprioception: overlooked training for runners and athletes with knee pain and other leg overuse injuries

After reading the title you’re probably wondering a few different things:

1. “What does balance have to do with being a good athlete?”
2. “What the heck is proprioception?”
3. “What’s for lunch today?”

These issues come up time and time again when I work with injured athletes from many different sports. I’ll address the first two questions and you are on your own for that last one.

Let’s review some anatomy first. There are specialized nerves in your joints, ligaments, muscles and tendons that help sense position and movement of your body. That sense is referred to as proprioception. Without these and other specialized nervous system parts you couldn’t close your eyes and know how your body is positioned at any instant. And you couldn’t stand up or walk in a stable manner. Clearly you don’t absolutely need vision to know where your body is or you would be watching your feet while you walk or run, right? By sensing position, these special nerves are also part of what keeps us stable so we aren’t just stumbling around like a drunk college student on Friday night. But many of us, even some of the best athletes, have poor proprioceptive awareness. For so many of us these proprioceptive pathways aren’t challenged often, and then the “use it or lose it” principle kicks in. Especially as we age, we begin to lose the efficiency of these specialized nerves. As these nerves degrade we can’t precisely place each leg with athletic movement. This decreased precision leads to poorer biomechanics that can be related to overuse injuries. Also, a previous or current sprain at the knee or ankle ligaments will negatively impact your positional awareness and movement precision because of the damage that a sprain will do to these special nerve endings. All in all, aging, previous injury and a lack of training stimuli are going to degrade the quality of your movement precision.

Do you think you have good balance and stability? Let’s find out in a couple simple steps. Try these in your bare feet.

1. Stand on one leg as long as you can without touching anything and count slowly. How many seconds can you last on each one? Less than 30 seconds? In that case you’ve got a lot of hard work to do. More than 30 seconds? Well that’s a good start but we’re only getting started.
2. Now stand on one leg as long as you can with your eyes closed. I bet most of you aren’t going to brag about this one. If you don’t make it to 30 seconds on one leg with your eyes closed then there’s likely to be some room for improvement in this aspect of your training.
3. If you have some kind of superhero balance, try standing on one leg, keeping the eyes closed and tilt your head backward or turn your head to each side. This is really hard and will likely stop all but the best balancers.

So what are you doing to train this aspect of your abilities? I imagine several folks are going to say “nothing” because they didn’t know it was important. For what is essentially very little effort, I’d suggest working on your balance, stability, and proprioception to improve your running and prevent injury. Here are a couple ideas to address this area:

1. Stand on one leg with your eyes closed. Sound familiar? If you are able to stand steadily on one leg with your eyes closed on a flat floor then stand on an unstable surface like a folded towel or pillow with your  eyes closed. Or, you could try moving your head as mentioned earlier. Aim for 30 seconds of the most difficult, but achievable, level. Switch sides.
2. Single leg Russian dead lift. One of my favorite exercises. In a standing position pivot your trunk forward from the hip of the weight-bearing leg. The other leg raises up behind you for every same degree the trunk goes downward. Don’t round your back. Repeat 8-15 times until the hamstrings and buttock muscles tire. Switch sides. You can do this with and without weight. 
3. Single leg step down. Stand on a single leg on the edge of a step. Drop down very slightly by bending the weight-bearing leg, keeping your weight back on your heel. Return to the start position. Don’t let your bending knee travel too far forward beyond the front of your foot. Think about keeping your buttock back. Repeat 8-15 times, at least until your hip muscles and quadriceps are getting tired. Switch sides. You can also do this with and without weight. 

Let me know how you do with these activities at mountainridgept@gmail.com. Easy? Hard? These skills become particularly important for runners and other athletes with overuse related knee pain, ankle pain and foot pain.