Although the speed of these athletes was remarkable what amazed me even more was how smooth they appeared.  Despite running at a pace that most of us would have trouble maintain for more than a lap or tow around a track, let alone for 26 miles, these runners appeared calm and relaxed, gracefully gliding through the air with seemingly little effort.  This is much different than what we see with many recreational distance runners, whose stride often appear jerky and strenuous.

Of course at the time I wasn’t quite sure what was so different, or what specifically made those strides so smooth and efficient, but I knew it was there.  I think most runners have experienced this.  We often see a runner and although we can’t quite put our finger on it or cannot clearly articulate it, we know when we see a good, smooth, efficient stride when we see it.

Over the years I have continued to be fascinated by the running stride, and continued to study running biomechanics from both the perspective of running injuries as well as a performance/efficiency viewpoint.  After videotaping hundreds of runners in my clinic, reading countless books and scientific articles on running, and reviewing video footage of world class athletes, certain patterns started to emerge.  Patterns that often distinguished higher level runners from recreational, slower runners.

One of the things that I started to see was that instead of having a forceful or obvious push off, great runners seemed to simply slide forward over their stance leg.   In contrast, with many recreational runners there is an obvious forward and upward push which often appears jerky and is associated with an obvious upward movement of the head and trunk.  This upward push with its associated vertical motion is a problem as it not only wastes energy, but will also place additional stress on muscles and joints of the lower extremity.

So why do virtually all world class runners share this characteristic smooth stride pattern.  Is there something inherently different about these runners or about how their bodies move that allows them to run so smoothly.  The short answer is yes, and one of the most basic things that elite level runners have that many recreation runners don’t is basic flexibility, particularly at the foot and hip.   It is largely this flexibility that allows them to smoothly glide over their stance leg, a situation I often refer to as ‘Gliding on the Pivot’.  Of course, flexibility is not the only thing that is required to be a elite distance runner, but with respect to stride mechanics a lack lack of flexibility will be sure to limit your stride.  Furthermore, although elite runners certainly possess other characteristics that we may not be able to attain (as they say, you can’t pick your parents), flexibility problems are something we can all improve upon.  So, to understand the importance of foot and hip flexibility in more detail let’s take a closer look at what normally needs to happen during the running stride.

Stride Mechanics 101 – Gliding on your pivot

As each leg contacts the ground during the running stride it forms a pillar of support for the trunk, and the trunk must pivot over the support leg to continue its forward progression.  This pivot initially occurs at the ankle during the early stance phase.  When watching elite level runners you can see how the ankle flexes, allowing the lower leg to rotate forward to  bring the knee past the toes.  As this happens the trunk is actually translating forward over the ankle joint (see Figures A-C in the image below)

During the second half of the stance phase the pivot changes from the ankle to the forefoot and hip.  First, as the body passes over the foot and the opposite leg swings forward past the stance leg the momentum of the body will cause the heel to lift off the ground, shifting the pivot point from the ankle to the ball of the foot. (This motion actually occurs at the joints formed at the base of the toes, the metatarsal-phalangeal joints (MPJ).  Under ideal circumstances it occurs primarily at the MPJ of the 1st and 2nd toes).  As the trunk continues to translate forward the hip joint will then extend past neutral, which allows the thigh to swing back behind the trunk.  This completes the pivot as the trunk has now translated past the stance leg, as which point the stance leg can begin the swing phase and be brought forward in preparation for the next stride (see Figures D-F below).

These are the patterns that are seen with virtually all elite level runners.  Go to a world class race, or browse around YouTube and you will consistently see these patterns.  Ideally, you would like to see this pattern in all runners, however, we know that this is not the case.  With many recreational runners, even accomplished runners who have been running their whole lives, we commonly see deviations from this pattern.  Instead of the trunk smoothly sliding forward and freely pivoting over the support leg we see jerky, awkward motions that waste energy and increases wear and tear on the body.  Next time you see these things in a runner look to see how the ankle, toes, and hips are extending.  There is a good chance that one or more of these segments will not be moving properly.

The real question is why do these motions not occur? The most common reason is that one or more joints are tight and lack the basic flexibility needed for a proper stride.  They are blocking the pivot.  As the normal pivot point is blocked, the body must adapt a new movement strategy to compensate for the restricted area.  One of the most common compensation patterns is that the ankle, knee, and hip extend too early in the stride in an effort to lift the body over the restricted joint.  This early extension creates an excessive upward push and excessive vertical motion. Instead of Gliding on their pivot they are forced to climb over it.

Testing Your Pivot

The most basic and fundamental aspect of developing an effective pivot is ensuring you have the required flexibility at the ankle, foot, and hip to allow your trunk to pass smoothly over your stance leg. This flexibility is critical because if these joints are restricted no amount of strength training or technique coaching will save you… you will be force to run with some form of compensation to make up for the restricted area.  So, the first thing to do is to test the flexibility of your joints that make up your pivot.  This can easily be done with the Standing Ankle Dorsiflexion Test, the Toe Extension Test, and the Modified Thomas Test.

Standing Ankle DF Test (SADFT)

Standing Ankle Dorsiflexion Test

I have found that the SADFT is the best way to accurately measure ankle motion. Stand facing a wall in a partial lunge position, with the toes of your lead against the bottom of the wall.  Keeping you heel firmly on the ground lunge forward to bring your knee to the wall.  It is important that you keep your knee directly over the foot as you do this.  If you can touch your knee to the wall without your heel lifting slide your foot back a few centimeters and repeat the motion.  Keep doing this until you can no longer tough the wall with your knee, this will represent your maximum ankle motion.

To quantify this test you can either measure the distance from your big to the wall, or you can measure the angle formed between your lower leg and vertical.Studies report that that normal ankle flexibility is consistent with a tibial angle of 50 degrees, or a toe-to-wall distance of 13.8 cm (1). If you scored lower that this it is an indication that your ankle motion is restricted.

Toe Extension Test

Toe Extension Test

Measuring the flexibility of the 1st toe in the clinic is often done with special measurement tools which most people don’t have lying around the house, but a quick and dirty way to test your toe flexibility is the kneeling Toe Extension Test.  From a kneeling position, keep both your heel and the ball of your foot flat on the floor, gently pull up on your big toe. Under normal circumstances you should be able to lift your big toe 2 inches off the ground. If you cannot lift the toe this high it is an indication that the muscles around your big toe, or the joint itself, is restricted.

Modified Thomas Test

Modified Thomas Test

The Modified Thomas is a classic test used to measure hip extension flexibility. Sit on the edge of a table or bed – your hip bones should be as close to the edge as possible. Lie back and pull one knee up to your chest while contracting your stomach muscles so your lower back is flat against the table.  Now let the opposite leg hang freely over the edge of the table (keep this leg completely relaxed).  You can use the angle formed between your thigh an horizontal as a measure of your hip flexibility.

Typically, angles between 0 to 10 degrees (meaning that the thigh is horizontal or just slightly below horizontal) are considered normal, however, research involving distance runners typically report higher values, ranging from 10 to 17 degrees (2,3,4).  This may reflect the need for greater hip extension during running compared with general daily activities.  In any case, it appears that hip extension measurements of 10 degrees or more are considered normal, however values of 15 degrees may be more desirable with higher level runners.

Mobilizing Your Pivot – Correcting Flexibility Problems

As a result of their effect on your stride mechanics, it is important that flexibility impairments are corrected.  Corrective stretching exercises are the first line of attack against muscle and joint restrictions.  In out clinic we have found that the most effective stretches to correct limited hip extension flexibility are the Kneeling Lunge Stretch and Standing Hip Extension Stretch.  To correct a tight ankle the Standing Ankle Dorsiflexion Stretch is often helpful.  Specific step-by-step instructions and accompanying video can be found on our website.  With respect to limitation in 1st toe extension, because of the nature of this restriction it is recommended that it be evaluated by an appropriate health care professional.

When stretching is not enough

In most cases stretching will help with flexibility problems, but in some cases muscle and joint tension can be resistant to traditional stretching.  As runners many of us have experienced situations where we stretch and stretch but muscles remain tight.  For these cases additional intervention is often needed.  This is related to the reason that muscles are often tight in the first place.

You see, with running, muscles often become tight from overuse. This is a product of the repetitive nature of running – as the same muscles stretch and contract thousands of times they are subjected to a process known as micro-trauma.  With this damage, new tissue forms to repair the damaged area.  The new connective tissue – commonly referred to as scar tissue or adhesion tissue – is dense and sticky, and muscle less elastic.  It can also cause the muscles to stick together and prevent them from sliding on one another, further limiting their flexibility.

Unfortunately, traditional stretching is not effective in dealing with these scar tissue adhesions.  Fortunately, these scar tissue adhesions are treatable with certain manual therapy methods. In our office, we have found that a specialized soft tissue treatment technique known as Active release Techniques®, or ART®, is extremely effective at identifying and treating scar tissue restrictions in runners and other endurance athletes.   In our office we have found ART® to be an invaluable tool in keeping runners healthy and moving freely, especially when combined with a proper stretching routine.

If you are unfamiliar with ART®, it is probably best described as a type of active massage.  The practitioner will first shorten the muscle, tendon or ligament, then apply a very specific pressure with their hands as the tissue is then stretched.  As the muscle lengthens the practitioner is able to assess the texture and tension of the tissue to determine if the tissue is healthy or contains scar tissue that needs further treatment.  When scar tissue adhesions are felt the amount and direction of tension can be modified to treat the problematic area.  As a result of its success in ART® is quickly becoming the treatment of choice for endurance athletes as it is so effective is keeping the muscle moving freely and efficiently despite high training mileage and intensity.

References

1) Bennell, K., Talbot, R., Wajswelner, H., Techovanich, W. and Kelly, D. (1998). Australian Physiotherapy, 44, 175-180.

2) Ferber, R, Kendall, K.D., McElroy, L. (2010). Normative and critical criteria for Iliotibial Band and Iliopsoas Muscle Flexibility.  Journal of Athletic Training, 45(4), 344-348.

3) Schache, A.G., Blanch, P.D., & Murphy, A.T. (2000). Relation of anterior pelvic tilt during running to clinical and kinematic measures of hip extension. British Journal of  Sports Medicine, 34, 279-283.

4) Harvey, D. (1998). Assessement of the flexibility of elite athletes using the modified Thomas test.  British Journal of Sports Medicine, 32, 68-70.

In an optimal swing the shoulders must fully rotate back relative to the hips.

One of the most important aspects of the golf swing is the shoulder turn. This rotation of the upper back is one of the biggest sources of power generation because as the shoulders turn in the backswing the trunk and shoulder coil around the rear leg. As this happens it places a considerable amount of stretch on the muscles of the trunk – especially the powerful abdominal oblique muscles. This stretch will “load” these powerful muscles, storing a tremendous amount elastic energy which can then be returned as the stretch is released during the downswing. One of the most important things to point out is that it is not the overall amount of shoulder turn that is important, but the degree of shoulder turn in relationship to the hips. Another way of saying this is that the shoulders should rotate back much more than the hips. With an optimal swing, the hips will rotate back about approximately 30 degrees while the shoulders will rotate back a another 50 -70 degrees past the hips. This relative position between the shoulders and hips is often referred to as the “X” factor, because when viewed from above the shoulders and hips form an “X”.

Swing Compensation: The Restricted Shoulder Turn

The restricted shoulder turn swing fault - note how there is less separation between the hips and shoulders

Making a full shoulder turn requires adequate flexibility from spine and upper back, particularly into a twisting or rotational direction. If this area is too tight it will restrict a full shoulder turn, which can be seen at the top of the backswing when the shoulders do not fully rotate to allow the upper back and shoulder blades to point toward the target.  It should also be pointed out that just because the shoulders have rotated so the upper back faces the target it does not necessarily mean that a full shoulder turn has occurred. Remember it is not just how far the shoulders have rotated, but how far the shoulders have turned relative to the hips that is important. In many cases shoulders will appear to make a full turn further analysis will reveal that the hips have turned back much farther than normal. Therefore, although it may appear that the shoulders have fully rotated they haven’t. The fully rotated position of the shoulders has occurred as a result of rotation of the lower body, not from the spine. This leads to an especially weak swing as it not only fails to “load” the trunk andshoulder muscles, but because the lower body has turned too much it restricts energy storage in the rear leg as well (see The Straight Leg Backswing for more information).

Correcting The Restricted Shoulder Turn Swing Fault

Since a Restricted Shoulder Turn is caused by tightness in the spine and upper back, to correct this swing compensation you must increase your flexibility in this area. An effective stretch to do this is the “Active Trunk Twist” which is part of the Performance Flexibility for Golfers Program. Take a few practice swings, perform the Active Trunk Twist Stretch followed by the Standing Trunk Rotation Stretch (it is important to do these stretches in this order), then take a few more swings. Remember to keep your rear leg stable as you take the club back. This will help you to prevent the hips form over-rotating. You should find that these stretches will help you to achieve a bigger shoulder turn, and lead into a more powerful downswing.

The Active Trunk Twist Stretch

1. Begin lying on your back with both knees bent and feet flat on the mat Your arms should be straight and resting on the floor beside you with the palms facing down (Figure 1)
2. In a slow and controlled manner, let the knees fall sideways toward the floor (figure 2).
3. As you do this, both shoulders should remain flat on the mat. If you cannot bring the knees all the way to the floor move only as far as possible without either shoulder lifting off the mat.
4. Hold this stretch position for 1-2 seconds and then pull the legs toward the mat on the opposite side (figure 3).
5. Repeat this back and forth motion 15 times.

Coming up in the next article…..The Dropped Tray Position Swing Fault

To develop power in the golf swing it is important to keep the lead arm (the left arm for the right handed golfer) remains perfectly straight during the backswing. This accomplishes 2 things: First, it keeps the hands as far away from the body as possible, creating a wider swing arc for the club to travel through. Essentially, swinging the club through a greater distance creates more acceleration and club head speed. Second, keeping the lead arm straight creates a greater stretch on the muscles of the upper back and shoulder. You should actually be able to feel this stretch in the back of your lead shoulder at the top of the backswing. Just as we saw when discussing the straight leg backswing, as the muscles are stretched energy is stored in the muscles, and that energy can be returned during the downswing to generate more power.

Correct backswing sequence: Note how the lead arm remains straight as the club is brought all the way back. This keeps the hands away from the body which produces a wide swing arc and "loads" the shoulder muscles creating more power.

Swing Compensation: The Bent Arm Backswing

Keeping the lead arm straight during the backswing requires a tremendous amount of flexibility in the upper back and shoulder – particularly at the Latissimus Dorsi, posterior Deltoid, and  rotator cuff muscles. If any or all of these muscles are tight they will not allow the upper arm to reach across the body to bring back the club. To compensate the elbow will bend in an effort to bring the club back behind the body, leading to a swing compensation known as the Bent-Arm Backsiwng. In this case, the bending at the elbow is compensating for the lack of movement at the shoulder. This may allow the club to be positioned fully overhead, but when this happens the stretch and energy storage of the Latissimus Dorsi and posterior shoulder is lost, which in turn results in a loss of power in the downswing. In addition, the bend in the elbow will make it more difficult to keep the club on-plane and will therefore make solid ball contact difficult, not to mention the additional strain this swing fault places on the elbow which will often lead to elbow injury.

Incorrect backswing sequence: As the arm passes 90 degrees the lead elbow bends. Note how this pulls the hands in closer to the body at the top of the backswing, making a more narrow swing arc and a loss of "muscle loading".

Correcting the Bent Arm Backswing

Since the Bent Arm Backswing is caused by tightness in the upper back and shoulder, to correct this swing fault you must increase your flexibility in this area. An effective stretch to do this is the “Standing Trunk Rotation Stretch”, which is part of the Performance Flexibility for Golfers Program. This is an Integrated Stretch which will not only target the upper back and shoulder, but because this stretch actually mimics the proper body position at the top of the backswing it will actually help train you body to reach this position during your golf swing. Take a few practice swings, perform this stretch, then take a few more swings. You should find that this stretch will help you keep your lead arm straight and you lower body more stable during the swing.

To Perform the Standing Trunk Rotation Stretch:

1. Begin in a standing position with both knees together and bent approximately 45 degrees (figure 1).
2. From this position, rotate the upper body as far as possible to the right as if you were trying to look at something behind. As you do this, do not allow the knees to turn or straighten. It is helpful to squeeze the knees together and concentrate on turning the upper body with the trunk muscles to prevent this from happening (figure 2).
3. Keeping the left arm straight, reach the left arm across the body.
4. Place the back of the right hand against the back of the left hand and use the right arm to pull the left arm and trunk further back into rotation – be sure to keep the left arm straight as you do this (figure 3).
5. Hold this stretch for 15-30 seconds and then repeat on the opposite side.

Coming up in the next article….The Restricted Shoulder Turn Swing Fault

Optimal Swing Technique: The Lead Foot Must Remain Firmly Planted

The transition between the top of the backswing and the downswing involves a slight weight shift onto your lead leg. This weight shift gets your weight moving forward as you strike the ball, but more importantly, it loads the muscles of the lead ankle, knee, and hip, transforming the lead leg into a stable pillar of support on which the upper body will rotate forward on during the downswing and follow-thru. Although it is a subtle movement, shifting your weight form the back lead to the lead leg is a critical part of the swing.

Although you need to shift your weight from the back leg to the lead leg during the downswing, problems with this transition usually begin in the backswing. For example, as the trunk, and shoulders rotate backwards it is important to keep the lead foot in full contact with the ground. This makes the transition into the downswing, and the shifting of your weight to the lead leg much smoother.

Swing Compensation: The Backswing Heel Lift

Keeping the lead foot in contact with the ground requires a considerable amount of flexibility from the hip and groin of the lead leg. If these muscles are tight, as the pelvis and trunk rotate back it will pull the lead leg with it. Because of the connection between the hip, knee, and foot, as the lead leg is pulled back it will cause the lead foot to twist and lose full contact with the ground. This can most commonly be seen as a lifting of the heel or outside of the foot at the top of the backswing. When this occurs it will interfere with the proper weight transfer and fail to establish the stability that is needed in the lead leg. In addition, it will often cause the foot to twist forward at the beginning of the downswing. This twist of the foot is a sure indication that the lead leg in not stable and that power generation has compromised as the link between your body and the ground has been lost.

Correcting the Backswing Heel Lift

Since the Backswing Heel Lift is caused by tightness in the hip and groin of the lead leg, to correct this swing fault you must increase your flexibility in this area. We have found that an effective stretch to do this is the “Anterior Oblique Sling Stretch”, which is part of the Performance Flexibility for Golfers Program. Take a few practice swings, perform this stretch, then take a few more swings. You should find that this stretch will help you keep your lead foot in better contact with the ground and lead to a smoother transition into your downswing.

To Perform the Anterior Oblique Sling Stretch:

1. Begin in a standing position with your left foot facing straight ahead and your right foot turned out 90 degrees.
2. Next, Take a wide step to the right (figure 1).
3. From this position, rotate your hips toward the right leg and perform a posterior pelvic tilt.
4. Holding this pelvic position, bend your right knee and slide your trunk forward toward your right foot. As you do this, you should feel the stretch increase in the left hip and groin (figure 2).
5. From this position, reach your left arm across your body and pull back on the left wrist with the back of your right hand. This will increase the stretch in the upper portion of the sling (figure 3).
6. Hold this stretch for 15-30 seconds and then repeat on the opposite side.

In the next article….The Bent Arm Basckswing

To better illustrate this point, in this article series I will discuss some of the most common swing faults, but instead of simply outlining what is supposed to happen, I will also discuss underlying causes of these swing faults with respect to the movement capacity of the body.  The first swing fault I will discuss is the ‘Straight Leg Backswing.`

The Straight Leg Backswing

Under optimal conditions, the backswing begins with a slight weight shift onto your rear leg. This acts to stabilize the rear leg allowing it to act like a pillar that your upper body can effectively rotate around as you bring the club back. To be effective it is essential that the back leg remains flexed as this occurs (i.e. the knee and ankle remains bent). When the back leg remains flexed the muscles of the ankle, knee, and especially the hip are forced to contract harder to support the weight shift.  This serves two critical purposes.  First, it provides a strong and stable base for the upper body to rotate around, which is critical for both the backswing and downswing.  Second, as the weigh shifts onto the flexed back leg the leg muscles are also “loaded” as the trunk and shoulders turn away from the target. (Recall from the first article in this series that as the muscles are `loaded` they act like runner bands and store energy).  This stores a considerable amount of energy in the rear leg. As you transition from the top of the backswing into the downswing the energy stored in the rear leg can be released and is used to drive the lower body forward, setting off the sequential uncoiling of the lower body, trunk, arms, and finally the hands.

Keeping the rear leg flexed during the backswing requires a tremendous amount of flexibility at the rear hip. Essentially, as the trunk and pelvis rotate back on the stationary leg in requires the hip joint to rotate internally.  When the hip joint or surrounding muscles become tight, the restricted range of motion will block the normal rotation that is required to hold the rear leg flexed and stable. Instead, when the muscles are too tight as the pelvis and trunk rotate back they will pull the rear leg with it, causing the leg to straighten out. This is a common swing compensation commonly referred to as the Straight Leg Backswing.

Although straightening the back leg effectively compensates for the restricted motion at the hip it also results in a less powerful swing. In fact, as the leg straightens out it will cause the bend at the ankle, knee, and hip to be lost, which compromises the ability of the back leg to act as a stable base of supper for the trunk and mitigates the muscle stretch and elastic energy storage in the leg. As less elastic energy is stored in the backswing, less energy is returned in the downswing, and less power is applied to the golf ball. As if a weaker swing wasn’t enough, the lack of power generation from the leg requires the trunk, shoulder, and arm muscles to work harder, which can lead to a number of conditions such as low back pain, golfer’s elbow, and shoulder tendonitis.

Correcting the Straight Leg Backswing

Since the Straight Leg Backswing is caused by a tight and restricted hip, to correct this swing compensation you must increase the flexibility in your rear hip. This is best done with a combination of soft tissue therapy (we find Active Release Techniques® (ART®) is an extremely effective method of releasing the hip) and at-home stretching.  An effective stretch to do this is the “Counter-Rotation Stretch”, which is part of our Performance Flexibility for Golfers Program (see below).

To perform the Counter-Rotation stretch:

1. Begin lying on your back with the knees bent and feet flat on the mat. From this position cross the left leg over the right, resting the left ankle on the right knee (figure 1).
2. Keeping the right foot in contact with the mat, let the right knee drop inward towards the mat. To increase the stretch on the right hip you can use the left leg to pull the right knee further in toward the mat (figure 2).
3. While maintaining this stretch reach your left arm across your chest.
4. Keeping the elbow straight let the left arm fall toward the floor by your right side. This will create a counter-rotation movement between the hips and shoulders (Figure 2).
5. To increase the stretch on the left shoulder, pull down on your left wrist with your right hand while keeping your elbow straight (figure 3).
6. Hold this stretch for 15-30 seconds and then repeat on the opposite side. Repeat 3 times per side.

Coming up in the next article, the Backswing Heel Lift….

In most cases it is not the advice that is incorrect, and it is certainly not from a lack of effort. Instead it is usually a matter of altered body mechanics.  Since an effective golf swing requires the integrated movement of the entire body, altered movement capability in one region can significantly alter the movement of other regions thereby sabotaging the entire swing. This article is the first in an extended series that will explore the golf swing in a new light. Within the following articles the biomechanics of the golf swing will be broken down into the key movements that need to occur at each area of the body, why these motions need to happen, and what will be the consequence if these movements are lost. Additionally, I will show you some simple ways that you can assess your swing mechanics, as well as assess key aspects of your strength and flexibility to determine why these stride faults are occurring.  The remainder of this article will introduce some key concepts that will need to be understood and will be built upon in future articles.

Swing Mechanics 101

The development of an effective swing requires the production of force and power from the muscles and joints of the body.  To understand how power is generated for the golf swing we must examine a few key concepts, The Kinetic Chain, Muscle Loading, and Swing Compensations.

The Kinetic Chain

To understand the golf swing we need to remember that our bodies consist not of individual parts, but instead a series of bones that are connected by joints and muscles. This connection between the various regions of the body is referred to as the kinetic chain. As a result the action of one area of our body can have a tremendous effect on other regions. In the golf swing, the kinetic chain begins at the feet, continues up to the knees and hips, goes into the trunk, into the shoulders, across the elbows and wrists and finally into the hands where the forces can be transferred to the club and finally to the golf ball during the downswing and contact portion of the swing. By moving the muscles and joints in a specific sequence the force that is developed within the body can be cumulative. In other words, when the golf swing is executed properly the forces produced along the kinetic chain can build on each other. The effect is the development of a far greater force than the individual muscle groups are capable of producing on their own. This is how elite golfers are able to achieve so much power and distance with their swings. Although individual muscles groups are not abnormally strong, they possess the joint range of motion and muscular control to take advantage of this force transfer system. As it will be see, even minor problems in joint and muscle movement prevents this force transfer effect making an optimal swing unfeasible and pre-disposing the golfer to injury.

Muscle Loading

What is meant by muscle loading is the application of a stretch to the muscles before contracting them. This increases the amount of force that muscles are able to generate because our muscles are highly elastic, and can actually work similar to a rubber band. As muscles are stretched energy is stored within the muscle, just like energy is stored in a rubber band. When we are ready to use the muscle that stored energy is returned, thereby increasing the ability of the muscle to generate force that can then be applied to the swing. Since this elastic energy requires little work to generate the force it is also very efficient and when used properly will help prevent muscle fatigue. This endurance is also important because as muscles fatigue the golf swing suffers and the susceptibility to injury increases. This concept of muscle loading through stretch is exploited in a proper backswing as the muscles of the thigh, hip, trunk, and shoulders are stretched and energy is stored within the muscles. This energy is then released in the downswing to maximize the amount of force and power available for ball contact. As we will see in subsequent articles, this concept of energy storage and release is a critical component of generating power and club head speed during the swing, but due to common muscle and joint restrictions very few golfers are able to tap into this important source of power.

Movement Compensation “A chain is only as strong as it’s weakest link”

As previously stated, when joints are moved through a specified range of motion it places sequential stretch on the muscles of the kinetic chain, which in turn stores energy within those muscles. This concept can be seen in the backswing as the joints are moved in order, starting with the hand and wrist, following up the elbow to the front shoulder, across the trunk to the back hip and finally into the back knee and foot. This results in a stretch and therefore energy storage all the way from the wrist to the feet effectively loading the muscles of the kinetic chain. In the downswing the stored power is harvested from the stretched muscles and transferred in turn from the lower body, trunk, shoulders, wrist and hands, and eventually through the club to the golf ball.  When the timing is right and the body uncoils in the correct sequence, the force generated at each region can actually be transferred to the next adjacent segment.  The effect is a much greater amount of force applied to the golf ball.
The problem occurs when there is a movement restriction at some location along the kinetic chain. When this happens it results in a movement compensation. Simply stated, a movement compensation is excessive motion at one area that occurs as a result of lack of motion at another area. When this happens it “breaks” the kinetic chain leading to a loss of the storage of elastic energy and therefore less force and power. Movement compensations are extremely common in recreational golfers and have a detrimental effect on the swing, both in terms diminished performance and an increased risk of injury. In fact, it is impossible to attain a biomechanically correct swing in the presence of movement compensations. When these movement compensations are present all the practice and professional advice in the world will not completely fix the golf swing. Instead focus must be on the identification and elimination of these movement compensations that are the true limiting factor in the swing. Only when these movement restrictions are dealt with can the power and grace of the optimal golf swing be reached.

Causes of IT Band Syndrome

The IT Band is a think, dense strip of connective tissue located on the outside of the thigh.  At the hip the IT Band makes a connection with the Tensor Fascia Lata and Gluteus Maximus muscles, and distally it attaches to the lateral aspect of the knee and lower leg.  As the knee flexes and extends the distal portion of the IT Band should slide over the bony projection on the outside of the knee.  However, with the repetitive strain of running and athletic training the IT Band often becomes tight and fibrotic.  When this occurs the IT Band rubs too hard against the outside of the, which in turn creates excessive friction and irritation in the IT Band.   As you continue to run the tight IT Band continues to rub against the outside of the knee and  it becomes even more irritated.  The more the IT Band becomes irritated, the tighter it gets, and the harder it rubs on the outside of the knee creating even more friction and irritation.  Essentially a progressive injury cycle develops creating more and more damage – this is why symptoms are often mild in the beginning and become more severe over time.

Addressing Abnormal Biomechanics Related To IT Band Syndrome

As illustrated above, the pain associated with IT Band Syndrome results from a tight IT Band, but to most effectively resolve the problem it is critical to determine why the IT Band has become tight in the first place. Although there are times where it is simply the repetitive strain of running itself that creates this tightness, more often than not there is some type of underlying biomechanical problem that has predisposed the IT Band to tightness and injury (this is why IT Band usually affects only one side, and also why the pain often come back if the underlying biomechanical cause is not corrected).

excessive hip adduction bas been shown to place excessive strain on the IT Band during running

A recent study published in the Journal of Orthopedic and Sports Physical Therapy found that runners with a history of IT Band Syndrome exhibited greater thigh adduction and internal rotation during the stance phase of running (1). Similar findings have been reported in other studies as well (2).  In plain language this means that runners with IT Band pain have a tendency for their thighs and knees to turn inward during the stance phase.  It is believed that this motion increases the strain on the IT band during running and is largely responsible for the development of IT Band Syndrome. Unfortunately, this biomechanical pattern of altered lower extremity alignment is extremely common in runners. In fact, I see this pattern in a large percentage of runners coming into the clinic, which predisposes a lot of runners to IT Band.  It should also be noted that this altered biomechanical pattern has been linked to other running injuries, including patella-femoral syndrome, which will be discusses in the next article in this series.

Treatment of ITBFS

As you can see from the preceding paragraphs, to best treat IT Band Syndrome it is critical to both 1) release the excessive tightness and tension of the IT Band itself to reduce the friction as the IT Band rubs against the lateral knee, and 2) to address any biomechanical problems that may be causing the IT Band to become tight in the first place.
We find a specialized type of soft tissue treatment known as Active Release Techniques® (A.R.T.®) is perhaps the most effective way to restore the normal tension and flexibility to the IT Band itself.  If you are not familiar with A.R.T.® you can think of it as a type of active massage. To apply treatment we first shorten the IT Band and then apply a very specific pressure with our hands as we stretch the tissues. As the tissue lengthens, we can assess the texture and tension of the IT Band issue to determine the specific areas of the IT Band that have become tight as well as which areas are not sliding properly over the lateral knee.  When problems are felt the amount and direction of tension applied with our hands can be modified to release the tension in the problematic area.

By taking the runner through a series of tests we can also identify related biomechanical issues that also need to be correct.  These tests begin with a treadmill analysis of running and walking, and then progresses to some functional assessment tests such as squats and lunges, and finally to an assessment of basic strength, flexibility, and range of motion of individual muscles and joints.  These tests can usually be performed during the initial assessment, unless the severity pain prevents it.  In that case the biomechanical assessment must wait a week or two until the pain subsides.
In our experience, the majority of IT Band cases respond very well to A.R.T.® treatment, especially when the biomechanical problems are also addressed.  In fact, although each case is unique and there are several factors that will determine the length of time it will require to fully resolve a condition, we usually find a significant improvement can be gained in just 5 – 6 treatments.

For more information on how A.R.T® may be able to help with your injury visit our website, www.KinetesisSports.com.

Click here to view our full report on Foot Pain

Plantar fasciitis can be amongst the most frustrating of soft tissue injuries.  Not only can this problem becomeextremely painful and completely stop you from running, walking, and other activities, but it can also be slow to respond to traditional methods of treatment.  This is partly due to the fact that the true cause of the injury is often overlooked.  For example, in many cases treatment is directed only at the foot – primarily to the plantar fascia itself.  Although treating the foot usually necessary, it is also important to determine why the plantar fascia has become strained  in the first place.  For example, in many cases the plantar fascia becomes over-stressed due to poor running biomechanics a tight or weak calf, or a problem in the hip.  If this is the case, in addition to treating the plantar fascia itself the biomechanics and other problems must also be corrected.  (By the way, this is why self-treatment is difficult for this injury. It is also why many people will get some initial relief with treatment, only to have the injury re-occur down the road).

Slow resolution of plantar fasciitis can also be a result of misdiagnosis.  You see, plantar fasciitis is often used as a ‘waste bucket diagnosis’, meaning that many practitioners automatically diagnosis any type of pain in the bottom of the foot or heel as plantar fasciitis.  This is far from the case.  In fact, there are several anatomical structures on the heel and bottom of the foot that can become painful in addition to the plantar fascia.  Obviously, the wrong diagnosis will limit the effectiveness of treatment so it is critical to check all the joints and soft tissues of the foot, ankle, and lower leg to arrive at the correct diagnosis.

How Does Plantar Fasciitis Develop?

With each foot strike the muscles of the foot must stretch and contract in an effort to absorb some of the impact force and provide a stable base for the knee, hip, and trunk.  Although the forces associated with each foot strike are far below the body’s tolerance limit, the repetitive nature of many athletic or occupational activities such as running or prolonged standing creates a situation where the stress and strain placed on the foot can actually build-up and accumulate.  Over time the muscles and the fascia can develop small amounts of injury known as micro-trauma.  Even though this micro-trauma is only small, this tissue damage still needs to be repaired, which the body does by laying down small amounts of scar tissue to repair the injured areas.  Unfortunately, over time as the same muscles are being stressed and subsequently repaired over and over, this scar tissue will build-up and accumulate into what are known as adhesions.  As these adhesions develop they begin to make the soft tissues of the foot tight and less flexible. As the tightness increases, the tissues begin to pull away from the heel where they attach, which will eventually lead to pain and irritation at the bottom of the heel.

In addition to pain in the heel itself, scar tissue adhesions can create problems in the deeper muscles of the foot as well.  From an anatomical perspective, it is important to realize that there are several layers of muscles in the foot, and that these muscles need to be able to glide freely on one another to maintain their normal function.  In addition to making muscles tight, scar tissue adhesions are very sticky.  As adhesions develop it causes the individual muscles and different muscle layers to stick to each other, preventing the normal gliding and relative motion between the muscles and fascia.  When the muscles lose the ability to glide over one another, it will bind the entire area together. In this sense you can think of these adhesions like rust and grime that can build-up in an automobile.  Normally the parts of the car should be well oiled and move smoothly, but when rust and grime are allowed to build-up the car begins to break down until eventually it does not work properly and repairs are needed.  The same thing happens in the body.  Stretching or contraction of one muscle will cause a pull and tension on all of the other muscles.  This in turn will cause more and more strain on the muscles as well as increase tension at the heel.

Addressing Abnormal Biomechanics Related To Plantar Fasciitis

Poor biomechanics are a big problem when talking about Plantar Fasciitis, especially in runners.  Biomechanics relates to how your muscles and joints move, stretch, and contract during movement.  Even if a minor problem such as muscle tightness, weakness, joint restriction, poor muscle balance, or bad posture exists, it will alter the foots biomechanics, causing the foot and ankle to move in a less effective, inefficient manner in an effort to compensate for the problematic area.  With poor biomechanics the degree of strain the foot is subjected to is be greatly magnified.

With respect to Plantar Fasciitis, perhaps the biggest biomechanical issue is related to pronation.  Pronation refers to a normal, inward rolling motion of the foot and ankle which should occur during walking and running as the foot makes contact with the ground.  This inward rolling is important as it helps to absorb the shock associated with foot strike. Unfortunately, either too much or too little pronation can create excessive stress at the foot.

With too much pronation (i.e. over-pronation) the foot rolls in too much, causing the arch of the foot to drop.  This motion places excessive stretch on the plantar fascia, creating irritiation to the fascia itself as well as it’s attachment point at the heel.  In addition, as the arch drops too much it forces the muscles of the foot to work even harder to prevent the over-pronation and maintain a stable foot.

Treatment of Plantar Fasciitis

As you can see from the preceding paragraphs, to most effectively resolve Plantar Fasciitis  it is critical to both address the build-up of scar tissue adhesions to restore the normal tension, motion, and flexibility of the plantar fascia and underlying foot muscles, as well as address any biomechanical problems that may be over-stressing the foot in the first place.

For the foot itself we find a specialized type of soft tissue treatment known as Active Release Techniques® (A.R.T.®) is perhaps the most effective way to deal with the scar tissue adhesions in the muscles and plantar fascia.   If you are not familiar with A.R.T.® you can think of it as a type of active massage. To apply treatment we first shorten the muscle, tendon, or fascia, and then apply a very specific pressure, with our hands as we stretch tissues. As the tissue lengthens, the we can assess the texture and tension of the tissue to determine if the tissue is healthy or contains scar tissue.  When scar tissue adhesions are felt, the amount and direction of tension can be modified to treat the problematic area.

By taking the client through a series of tests we can also identify related biomechanical issues that also need to be correct.  These tests begin with a treadmill analysis of running and walking, and then progresses to some functional assessment tests such as squats and lunges, and finally to an assessment of basic strength, flexibility, and range of motion of individual muscles and joints.  These tests can usually be performed during the initial assessment, unless the severity of the foot pain prevents it.  In that case the biomechanical assessment must wait a week or two until the pain subsides.

In our experience, the majority of Plantar Fasciitis cases and other foot problems respond very well to  A.R.T.® treatment, especially when the biomechanical problems are also addressed.  In fact, although each case is unique and there are several factors that will determine the length of time it will require to fully resolve a condition, we usually find a significant improvement can be gained in just 5 – 8 treatments. For more information on how A.R.T.® may be able to help your foot problem view our full report by clicking here, or visit our website, www.KinetesisSports.com

Perhaps the biggest barrier to efficient movement and performance are fibrous scar tissue adhesions that form in and around the soft tissues of the body.  These adhesions, which are a consequence of physical stress and overload acting on the body (see below), make the muscles and other soft tissues both tight and weak, which in turn will compromise the body’s ability to move properly.  For example, when a muscle becomes tight and fibrotic not only will it not stretch and move as well, but because scar tissue adhesions interfere with a muscle’s ability to contract properly it can also limit strength and force production.  Obviously compromised strength and flexibility are problems in their own right as they can directly lead to reduced performance, but since you are still asking your body to perform the same tasks day after day your body is forced to move differently to compensate for the problematic areas.  These altered movement patterns – known as movement faults or movement compensations – can be very problematic as they can 1) waste energy and make you  much less efficient, and 2) create excessive stress at other areas of the body as they have to work harder to compensate for the weak areas.

These compensation patters essentially set up a progressive cycle of dysfunction in which the muscles that are forced to compensate for the initial problem eventually become overloaded and develop scar tissue adhesions, which in turn makes these muscles tight and weak.  Eventually the body must adopt yet another new movement strategy to compensate.  As this process continues at some point the body will run out of ways to compensate and injury will occur, but as you can see, long before this happens the body’s performance capacity and efficiency will be significantly diminished.

How Do Scar Tissue Adhesions Develop?

Unfortunately, the type of training that athletes must do also carries with it the potential to stimulate the formation of scar tissue adhesions in and around the soft tissues (i.e., muscles, tendons, fascia, nerves, ligaments, and joint capsules).  You see, unlike exercising for general health and wellness, the intensity and duration of training required to make significant athletic improvements places a considerable amount of strain on your muscles and joints. This can create small scale cellular damage in your soft tissues known as micro-trauma.  Although only small, your body must still repair this damage, which it does by laying down new tissue (i.e. scar tissue) in and around the injured area.
It is important to realize that in and of itself this inflammatory/repair process is a normal part of healing.  The real problem occurs due the repetitive nature of athletic training.  As you train you continue to perform the same movements over and over, which in turn stresses the same tissues day after week after month.  Essentially this sets up a cellular environment of chronic inflammation and ongoing soft tissue repair.  Keep in mind that this inflammatory/repair process results in scar tissue being deposited in the damaged tissues.  Over time the amount of scar tissue builds up to point where the tissues become tight and weak (at this point the scar tissue build-up is often referred to as an adhesion).

Unfortunately, even with proper biomechanics and following a proper training program some amount of adhesion formation is going to occur – this is simply the nature of athletic training (remember, to stimulate positive adaptation athletes need this intense athletic training).  So it is not practical or realistic to try to prevent these processes from occurring.  The better strategy is to deal with adhesion formation before it builds up to the point where it affects movement and compromises performance.

Treating Scar Tissue Adhesions

In our clinic we have found that the most effective method to keep an athlete’s soft tissues healthy and moving properly is with a soft tissue technique known as Active Release Techniques® (ART®).  ART® is a state-of-the-art soft tissue treatment system designed to identify and treat scar tissue adhesions, and it is quickly becoming the treatment of choice for injuries and dysfunction to muscles, tendons, nerves, etc.  If you are not familiar with ART® you can think of it as a type of active massage. To apply treatment we first shorten the muscle, tendon, or fascia, and then apply a very specific pressure, with our hands as we stretch the tissues. As the tissues lengthen we can assess their texture, tension, and health to determine if they are healthy or contain scar tissue.  When scar tissue adhesions are felt, the amount and direction of tension can then be modified to treat the problematic area, helping restore normal texture, tension, strength, flexibility, and function to the tissue.

This approach works great with soft tissue injuries, but for athletes we can take this approach one step further and can actually work to identify problematic tissues before they start to significantly affect performance.  We refer to this process as ART® Performance Care.  The process involves evaluating the athlete for any biomechanical problems such as restricted motion or flexibility.   Once these problems are identified we can then perform a more focused assessment of the problematic area to determine exactly which tissues have become restricted, which can then be corrected through ART® treatment. We have found this approach to be invaluable in keeping athletes healthy and able to train and compete at their highest level, so if you are an athlete who wants to keep your body healthy and able to move and compete at your optimal level make ART® Performance Care a part of your regular training and preparation.

]]> http://kinetesissports.com/blog/?feed=rss2&p=154 0 http://kinetesissports.com/blog/?p=141 http://kinetesissports.com/blog/?p=141#comments Tue, 26 Oct 2010 14:36:01 +0000 Dr. Jason Gray http://kinetesissports.com/blog/?p=141

Click here to view our full report on resolving running injuries

Studies of both competitive and recreational runners have estimated that between 45% and 72% of runners will sustainan injury over the course of a year (1-4).   Among those training for marathons, the injury rate can be as high as 92% (5).   Now here is the really interesting thing…the vast majority of these injures can be prevented! If this is the case, why are there so many injuries?  Well, in my experience it comes down to two things: first, the majority of runners get caught up in what they need to do to improve their running, but they forget that a big part of run training is keeping their body healthy.  This is a huge mistake considering that more than half of the running population will become injured in any single year.  Second, most runners don’t really understand how running injuries develop.  They think that most running injuries occur simply as a result of over-training.  As a result, they think all they need to do to prevent injury is avoid increasing mileage and intensity too quickly.  However, this is an extremely oversimplified view of running injuries.  Recent research has shown that there is much more to running injuries than just over-training.

So, the purpose of this is to 1) lay the foundation for how running injuries develop, including tissue degeneration and the link between running biomechanics and injury; and 2)  introduce the modern sports medicine approach to injury treatment and prevention.

The Cause of Running Injures – The repetitive strain injury cycle

Running injuries are overuse injuries, which occur slowly over time when the body is exposed to a large number of repetitive forces producing a combined fatigue effect over a period of weeks, months, or years (6,7).  With running, each time the foot strikes the ground forces are transmitted up the kinetic chain.  Although the forces associated with each foot strike are far below the body’s tolerance limit, because of the repetitive nature of running (for example, a typical training week entails tens of thousands of foot strikes) the stress and strain associated with each stride can actually build-up in the body over weeks and months of running.

As time goes on and the runner continues to train and compete, the strain imposed on the body will develop into micro-trauma.  Although only small, this tissue damage still needs to be repaired, which the body does by laying down new connective tissue (commonly referred to as ‘scar tissue’) to repair the damaged area.   This process of tissue damage and repair is a normal and necessary part of healing; however, with running, because the body is exposed to the same repetitive, high impact forces of running day after it often sets up an environment of chronic inflammation and ongoing tissue repair.

Over time, these scar tissue will build-up and begin to place more and more strain on the muscles as they must now stretch and contract against these adhesions with each stride.  This places even further strain on the kinetic chain, which in turn leads to more micro-trauma.  Essentially a repetitive injury cycle is set-up causing continued adhesion formation and progressive movement dysfunction.  At this point it is not uncommon for the muscles to give way and a more severe pain to occur.  In fact many runners come into our office explaining how they have had an injury but have not done anything different that may have caused the pain.  When further questioned these runners almost always describe some mild pain or tightness that has been building over time.  As you can see from the explanation of this repetitive injury cycle, these types of injuries build-up over time and the more acute injury is often just the “straw-that-broke-the-camels-back.”

Movement Compensations – The Link Between Biomechanics and Injury

Any discussion of running injuries must also consider the impact of poor biomechanics.  In fact, in addition to training errors such as increasing mileage or intensity too quickly, it has been suggested that most overuse injuries are also associated with some underlying anatomical or biomechanical problem(8).  Running biomechanics relates to how your muscles and joints move, stretch, and contract during the running stride.  Coaches and sport scientists have studied the strides of elite and recreational runners extensively and have found that although there is some normal variability across runners, there are certain key motions that must be present with all strides.  Even if a minor problem such as muscle tightness, weakness, joint restriction, poor muscle balance, or bad posture exists, it will alter the runner’s biomechanics, causing the body to move in a less effective, inefficient manner in an effort to compensate for the problematic area.  In running, this alteration in body movement is referred to as a “stride fault” or “stride compensation”.  Due to the repetitive nature of running even minor movement problems will be greatly magnified and will prevent the runner from properly controlling the impact forces associated with each stride.  This will greatly amplify the effects of the repetitive strain injury cycle, accelerating the accumulation of strain on the body.  Although it is beyond the scope of this article, the following articles in this series will review the most common stride compensation patterns and how they relate to specific running injuries.

Resolving Running Injuries – The Modern Approach

Years ago treatment for joint and soft tissue injuries tended to focus primarily on the area of injury itself, the goal being to restore the injured area to its pre-injury state.  Although this process remains necessary, our evolving knowledge of sports science and injury mechanism dictates that this by itself is not enough – a conscious effort must also be made to correct any biomechanical problems and running compensations – after all, it is these compensations that are causing the body to become injured in the first place.   In fact if poor biomechanics are not addressed the chance of re-injury is not just a possibility, but is almost a certainty.

Preventing Running Injuries

Of course, working towards prevention of running injuries is the optimal strategy.  As you can see form the first half of this article, running injuries develop slowly over time due to the accumulation of strain.  Therefore, to prevent injuries you must address this strain, which can be done by 1) minimizing the strain associated with running; and 2) addressing the scar tissue adhesions that accumulate from run training.  Minimizing strain to the body can be done either by running less, or improving your biomechanics.  The latter is the more preferable option as it allows you to maintain running volume and intensity that is needed to stimulate training adaptations.

The second element of injury prevention is addressing scar tissue adhesions.  Unfortunately, with run training it is inevitable that adhesions will develop within the soft tissues (even with optimal biomechanics adhesions will develop, but with poor biomechanics the will build up much faster and have a more significant effect).  In the initial stages the effects of these adhesions will be minimal. It is only when these adhesions accumulate beyond a ‘critical level’ that they will begin to compromise health and performance.  Fortunately, scar tissue adhesions can be addressed with several manual therapy techniques, perhaps the most effective being a specialized soft-tissue technique known as Active Release Techniques (A.R.T.).   In our office we find that regular maintenance treatments utilizing A.R.T is an extremely effective way to treat the adhesions that accumulate in soft tissues, keeping runners healthy and able to perform at their highest level.

Hopefully this article has helped shed some light on running injuries, and has provided you with a more thorough understanding of how to best treat running injuries, and even prevent running injuries before they occur.  For more information on specific running injuries, download our full report on running injuries, or visit our website, www.KinetesisSports.com.

References

1.    Marti et al., 1988
2.    Jacobs & Berson, 1986
3.    Bennell & Crossley, 1996, Walter et al., 1989
4.     Lysholm & Wiklander, 1987
5.    Satterthwaite, Larmer, Gardiner, & Norton, 1996
6.    Schache et al, 1999
7.    Hreljac, Marshall, & Hume, 2000
8.    Hreljac et al. 200