runners & Pain: Special report

Your body is to blame for your pain, but not in the way you think. Your guide to MOVING MORE EFFICIENTLY WITH three self assessments.

If you’re an athlete, your body is the most important tool on the course, field, track, etc. Many will struggle with ongoing pain and injuries for years before seeking help. Some wear it as a badge of honor. Others are tired of empty promises and simply don’t know where to turn. The intention of this article is to empower you with information about how your body could be the limiting factor in your overall efficiency and what you can do to move beyond that pain. 

A recent article from Scott Douglas of Runner’s World, indicated that of 933 new runners, 254 (about 30%) met the definition of having a running injury during their first year. Other new research indicates that as many as 79% of runners get injured at least once during the year. This could indicate that as many as 50% of seasoned runners will battle with their bodies throughout the season. 

From my experience in treating sports injuries and applying movement therapy, your body drives your form

Structural Imbalance Decreases Efficiency

When an athlete walks in my door the first thing we look at is how they move. This does a number of things: 

-      It tells me if they are suffering from a mobility issue (the joint cannot complete the full range of motion) or a stability/motor control issue (the athlete doesn’t have a good mapping system for the muscles of a specific joint or movement). 

-      The movement assessment will also tell me if there is pain with any of those movements. Oddly enough, when someone presents with pain, I don’t often care where they present with pain. It’s likely that the area of pain is the part of the body that is working correctly, just too much as some other body part isn’t doing its fair share (e.g. Your roof leaks. It stains the ceiling and potentially ruins the floor. If your only fix is to mop the floor and replace the material of the floor or ceiling, you’ve missed the cause of the problem.). 

-      Lastly, the movement screen removes bias in treatment. Test, treat, re-test. If the treatment rendered does not improve the failed movement, a different approach is needed.  

So now we know where your movements lack (structural imbalances). What does this have to do with efficiency? 

Try this postural experiment.

 What did we learn?

When the joints of the body aren’t aligned or no longer centrally located, compensation occurs. Other tissues have to fire to do the job, potentially rendering the movement slower and less powerful. This has the potential to abnormally wear down the tissue or joint. Creating pain or leading to injury. 

Three Common Structural Imbalances (w/ one surprising omission)

These “3 Most Common…,” are issues I see and treat every day in clinic. The type of athlete matters little, the type of movement the athlete exhibits, matters most. 

  1. Hip Mobility

One huge clinical pearl, as physicians will often say, is that the overwhelming majority of low back issues/pain (experts will say over 90%) stems from poor range of motion or stability of the hip itself. 

The logical athlete may think to themselves, “Well wouldn’t that then be hip pain and not low back pain?” 

-      Poor range of motion in a joint often does not include pain. However, the body recognizes the insufficiencies and moves around it. The body works in varying patterns of shared motion. So, it reasons, if one part of the body is doing more than its fair share, it is then overloaded, or used inefficiently.

This photo exhibits what abnormal loading can do to tires. There is nothing inherently wrong with the abnormally worn tire, it was just loaded more than the other. Increasing its potential for blowing out sooner.

This photo exhibits what abnormal loading can do to tires. There is nothing inherently wrong with the abnormally worn tire, it was just loaded more than the other. Increasing its potential for blowing out sooner.


Number one on my list, and this rings true for nearly any athlete of any sport, is proper hip mobility.

Pelvic Positioning Control


Hip Extension Mobility

The hip joint is a mobile joint. Meaning it should be able to move in nearly any direction. In runners, we see significant limitation in flexion (bringing the knee closer to the trunk) and extension (kicking the heel towards the rear). These types of limitations increase load on the ankles, knees, and low back. The assessment above will help show you if either of those are limited. The excerpt below is from Running Rewired.

“When you run, especially as your speed increases, more and more oomph needs to come from the muscles that extend the hips. It’s likely that years of overstriding (over a decade of research indicates as much) have wired your muscle memory (motor mapping) to favor the quads and neglect the glutes. Said simply, the typical runner is quad-heavy and glute-light.”

2. Foot & Ankle Adaptations

It’s unfortunate the number of athletes that come in my door that have no idea how well (or poor) their feet and ankles interact with the ground. So much so, we have seen a huge uptick in research and training products to evaluate ground reaction forces (GRF) (how well the foot pushes back into the ground to create power). If inefficiency is found here it doesn’t matter what happens up the chain (well, not as much).

The foot is often the only part of the body interacting with an outside object creating potential energy in say running, golfing, batting, throwing, etc. Golfers and pitchers, as you can see below, use a tremendous amount of GRF to deliver rotational forces throughout the body and efficiently into the ball.

In the 2017 season, Justin Thomas was one of four players who earned the most official prize money and had driving distance averages of more than 300 yards. He weighs 145lbs.

In the 2017 season, Justin Thomas was one of four players who earned the most official prize money and had driving distance averages of more than 300 yards. He weighs 145lbs.

An efficient push off of the rubber for pitchers significantly increases ball velocity.

An efficient push off of the rubber for pitchers significantly increases ball velocity.

  1. With foot about a fist width away from the wall, move the knee towards the wall as far as you can without the heel coming up. There should be minimal hip movement to the side as well.

  2. Standing on both feet, try to lift the big toe while the other toes press into the floor. Then, do the same thing with the toes coming off the floor separate from the big toe.

  3. Single Leg Balance check. Which one feels better? Could you hold it easily for 10-15 seconds?

  4. Ankle inversion and eversion keeping knees still.

What did we learn?

Your ability to find neutral in the foot and ankle directly impacts the way we absorb the pounding of heel strike into mid stance of the running cycle. Not only that, but lack of that skill or technique, decreases your ability to effectively push into the ground and out of the position, called the Windlass Mechanism (see video).

The inefficiency of this mechanism leads to issues of the calf and foot. Things like: plantar fasciitis, heel spurs, shin splints, high ankle sprains (or ankle sprains in general), achilles tendinopathy/tendonitis, calf strains, stress fractures, and a whole host of issues with the knees. Not to mention decreased performance and enjoyment of the sport.

3. Previous Injury

Wait, what?

Yup. Actually, the #1 predictor of a future injury is… a previous one.

Did you know, athletes that had an ACL tear were more than 6x more likely to reinjure the same knee or even the opposite (healthy) knee than a healthy control group? Athletes that suffer an ankle sprain are upwards of 80-85% more likely to reinjure that ankle than a healthy control group? Those who suffer a concussion were 3x more likely to suffer another one. The list goes on.

Regular exercise has a way of uncovering the weak areas of your body. If you have imbalanced hip muscles, for example, or knees that are put under heavy stress because of your unique biomechanics during exercise (‘poor form’), your hips or knees are likely to be hurt when you engage in your sport for prolonged periods of time.

After recovery, if you reestablish your desired training load without changing your biomechanics or balancing your hip muscles, those areas are very likely to be injured again.

Strangely enough, the second-best predictor of injury, is probably the number of consecutive days of training you carry out each week. Consecutive days are counted as follows: if you train on Monday, Tuesday, Wednesday, and Friday, you are training on three consecutive days each week (Friday doesn’t count because it has a rest day before and after it).

Scientific studies strongly suggest that reducing the number of consecutive days of training can lower the risk of injury. For example, instead of working out for one hour from Monday through Friday (five consecutive days), you could probably reduce your risk of injury by completing 75-minute workouts, four days per week (Monday, Wednesday, Friday, and Saturday, for example).

Your total training time would be the same in each case, but the second strategy would reduce your consecutive days from five to two, giving you much more average recovery time between sessions and lowering your risk of injury. Recovery time reduces injury rates by giving muscles and connective tissues an opportunity to restore and repair themselves between workouts.

the omission

The knees.

Many runners, in fact nearly every runner I’ve treated, complain of knee pain.

So why aren’t the knees to blame?

The body works in alternating patterns of stable segments connected by mobile joints. If this pattern is altered - dysfunction and compensation will occur. The knee is a stable segment. It only likes to move forward and back. It’s true it does have some rotational aspects to it’s movement, but it doesn’t like to do that over a long period of time. If we lack mobility in the hips or ankles, the knees are no longer stable. They are required to pick up extra range of motion to compensate for the other areas.

Other issues that cause knee pain include tight quads, tight IT band, tight hip flexors, tight lower leg muscles (muscles of the shin and calf), and tight adductors among others.

So we should just loosen those muscles up then right?

Maybe. They could be tight because they are overused, they could be tight because they are doing all of the work (releasing them in this case could set you up for more dysfunction), or they could be tight because of other structural issues.

You can find out below if your hips or feet could be contributing to your knee pain.

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How did you do on the self-assessments? Did you notice some things that you weren’t aware of before?

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