Summary of running retraining considerations for knee and hip pathologies, including potential biomechanical rationale for retraining strategies
| Retraining considerations | Illustrative quotes | Potential biomechanical rationale for retraining considerations |
|---|---|---|
| PFP | ||
| Running retraining strongly advocated Consider increasing step rate, strategies to reduce overstride and impact loading variables, reduce peak hip adduction* and internal rotation, and promote more forward trunk lean | “Most common thing with patellofemoral would be over-striding and also medial collapse, particularly the females … Then the third one would be the one that I would call the very upright running posture with the trunk. The runners that tend to run like that, they tend to have very low hip moments and very high knee extensor moments. So for those folks, we'd work on some anterior trunk lean.” (2) “Probably two major things which will lead to patellofemoral pain … there will be excessive hip adduction, internal rotation. So, that's something you often look to change. And the other thing will often be that the runner will be over-striding and landing with a particularly heavy heel strike.” (6) “With patellofemoral, again we found that by changing those sagittal plane kinematics (reducing over-striding and increasing cadence), we noticed a change in frontal plane kinematics as well … some of that knee valgus and hip adduction was reduced as well.” (9) “The one area that has the most evidence would be patellofemoral pain … if you see them banging really hard, over striding and hitting with those high impact forces, then you might try to soften those impact forces.” (14) | Cues to reduce hip adduction*—limited evidence indicates ↓ peak hip adduction and contralateral pelvic 3 months follow-up in a PFP population22 23 Increasing step rate—strong evidence indicates ↓ peak PFJ stress/load including in a PFP population68 75 96 and ↓ peak knee flexion66 75 68; and limited evidence indicates ↓ knee energy absorption,59 63 66 and ↓ internal knee extensor moment63 71 73 75 Cues to increase forward trunk lean—limited evidence indicates ↓ PFJ stress and reaction force, ↑ PFJ contact area, and ↓ internal knee extensor moment and knee flexion at time of peak PFJ stress88 Transition from rearfoot to forefoot strike—limited evidence indicates ↓ peak and accumulative PFJ reaction force and PFJ stress94 96 |
| ITB syndrome | ||
| Running retraining advocated by some experts Consider strategies to reduce hip adduction and increase step width (address cross over gait) | “The pathomechanics (to change) would be medial collapse mechanics, excessive hip adduction and the other one would be cross-over gait pattern.” (2) “We have success with people who have not had any success with the typical strengthening of their glutes and stretching of the IT band and rolling, form rolling. It's amazing! And all we do is (reduce) their hip adduction.” (4) “We reduced tension within the ITB by, with a wider stance of gait. And sometimes I think you know, that does help … I found that the biggest change to ITB has been activating those big muscles. Again coming back to that high knee lift which then results in a greater activation, I think, of hip extensors of the opposite side.” (9) “With IT band, it tends to be more dealing with the problems rather than the gait retraining component of it … I can think of a couple of patients that were—That crossed over and they got IT band. They would get IT band syndrome because they crossed over. And then in those cases, you do think about (promoting) maybe a little bit wider stride.” (14) | Cues to reduce hip adduction—limited evidence indicates ↓ peak hip adduction and contralateral pelvic drop at 3 months follow-up22 23 Cues to increase step width—very limited evidence indicates ↓ peak internal knee abduction moment,84 ↓ internal knee abduction impulse,84 ↓ ITB strain and strain rate,85 and ↓ peak hip adduction84 85 |
| Patellar tendinopathy | ||
| Cautious recommendations for running retraining to assist by some Consider increasing step rate, strategies to reduce overstride and impact loading variables, and transition from rearfoot to forefoot strike | “You often find these individuals very different to patellofemoral pain where you'll get a greater hip adduction. They often have good hip control, but they do have the over-stride pattern where they're landing quite heavy on the heel (which should be changed). And essentially, they're just not absorbing any shock to their foot and ankle, it's all going straight to the knee, which means you're gonna load up the patellar tendon.” (6) “Patellar tendinopathy … My first part of the treatment will be to protect the tendon if it's acute, I will say to the patient, okay, just increase the cadence, lowering the shoes so more minimalist shoes in acute condition, and be sure that you don't cause another problem in another place at the same time, less noise, and if it's not enough, forefoot striking.” (10) | Increasing step rate—moderate evidence indicates ↓ peak knee flexion66 68 75; and limited evidence indicates ↓ knee energy absorption,59 63 66 ↓ internal knee extensor moment,63 71 73 75 ↓ patellar tendon force in midstance68, and ↓ quadriceps (vastii) muscle forces during stance68 Transition from rearfoot to forefoot strike—limited evidence indicates ↓ knee power absorption92 |
| Hamstring, including proximal hamstring tendinopathy | ||
| Running retraining generally advocated but some inconsistent beliefs regarding how, particularly in relation to trunk position Consider strategies to reduce over stride and impact loading variables, reduce anterior pelvic tilt and knee extension at foot strike, and increase swing phase hip and knee flexion | “Yep and I often see over-striders … I often see kinematically that they are, have got a very stiff knee strategy (which needs to be changed). (5) “Hamstring is always a classic over-stride pattern … Just changing that and getting them to try and often think about landing more softly, so that they land a lot more under their body” (6) “These guys at the foot strike position were leaning forward a bit too much and over-extending the knee. So if we reduce the knee extension at the foot strike and straighten the body up as well, perhaps that reduced the stretch or the tension within either the hamstring or some of those neural structures.” (9) “I would be looking for anterior pelvic tilt, control of anterior pelvic tilt, and then maybe control of even internal rotation of the hip (with running retraining).” (14) “I think the high hamstring group often tend to, again, have really poor swing phase hip mechanics … The running mechanic that I might wanna look to (change) is actually trying to reinforce that capacity to have good hip-knee flexion during swing phase.” (16) | Increasing step rate—limited evidence indicates ↓ hip energy absorption63 66 ↓ peak internal hip extensor moment66 71 |
| Gluteal tendinopathy | ||
| Running retraining advocated by most experts Consider reducing overstride and increasing step rate, and reducing hip adduction, internal rotation and contralateral pelvic drop | “(In gluteal tendinopathy) One (variable to change) would be over-striding and then the other one would be excessive hip adduction, specifically excessive pelvic drop.” (2) “It's more just controlling that femoral internal rotation adduction and try to get them think about tightening their glutes, opening their knees up, and often that tends to make a big difference with them (gluteal tendinopathy patients).” (6) “I'm interested in what's happening through that sagittal plane (in runners with gluteal tendinopathy), but I'm really interested in what's happening through coronal plane and rotational as well. So I wanna decrease that hip adduction-internal rotation that's potentially compressing that tissue and I will do that through rehabilitation and I will, again, because I don't think rehabilitation on its own changes gait, and I'll also do that through gait modification.” (16) | Increasing step rate—limited evidence indicates ↓ hip energy absorption,63 66 ↓ peak internal hip extensor moment,66 71 ↓ peak hip adduction22 23 and ↓ gluteal muscle forces during stance68; and very limited evidence indicates ↓ peak internal hip abduction and external rotation moments66 Cues to reduce hip adduction—limited evidence indicates ↓ peak internal hip abduction moment at 1-month follow-up,22 and ↓ peak hip adduction and ↓ contralateral pelvic drop at 3 months follow-up22 23 |
*Retraining strategy part of successful case series intervention in this condition.
†Concurrent conflicting expert opinion regarding this retraining strategy.
ITB, Iliotibial band; PFP, patellofemoral pain.