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Learn more about Rehab, Sports Medicine & Performance


Very Short Term Running Preparation

I was recently asked by a fitness client to post exercise recommendations that would prepare her for outdoor distance running.  This person was two weeks away from being out on the road, running two or three miles a day.  She is middle aged, has a prior history of lower back pain, and her goal was to lose fifteen pounds and “tone up”.   Given such short notice, these are my recommendations.

Perform soft tissue work on a daily basis.  Foam roll the legs and use a lacrosse ball on the plantar fascia.  The vast majority of overuse injuries in runners happen in the lower legs and feet.  Attempt to unwind the myofascial distress created by 600-700 foot impacts a mile.

Improve your reciprocal hip pattern–one hip goes back and the other goes forward.  Most general fitness clients have glaring deficits on one side.  Perform some split squats, posterior lunges, step ups, and or walking lunges.  If you struggle with these activities, I would reconsider running as a fitness activity.

Wake up your gluteals.  Every day, perform fifty or sixty bridges, hip lifts, or leg curls.  You need super gluteal strength / endurance to run distances and avoid lower extremity injury.  If your butt gets sore from fifty bridges, you need to do them more often.

Running is a skill and most recreational runners need some practice.  Running hills will improve gait mechanics, enhance hip extension, and decrease deceleration forces.  Find a fifty-yard hill.  Run up the hill and walk back down.  Perform five hill runs.

You are always better to run too little than to run too much.   Start with very short runs– no more than half a mile.  Increase your total weekly mileage by no more than five percent a week.

You can’t do this in two weeks, but this is my big recommendation to all future runners.  Lose the extra weight before running.  As a method of fat loss, distance running has a poor track record.  It tends to elevate the hormones that make you hungry, and physiological adaptation to distance running happens fairly quickly.  Extra adipose makes you far more likely to develop a running related injury.  I know the guys and gals you see running miles and miles every day are lean.  Please remember that lean runners are successful with running because they possess the optimal body mass to run long distances.  They did not start heavy and become lean.  Put a fifteen pound weight vest on that guy or gal and everything will change.  Their gait will lose efficiency and become less graceful.  The extra fifteen pounds of load creates the biomechanical overload that makes them much more likely to suffer an injury.

My final recommendation is that you not become disappointed if you develop pain.  A runnersworld.com poll conducted in 2009 revealed that 66% of respondents reported a running related injury that year.  The statistics indicate that one third of the participants at you local 10k fun run will require medical attention for a running related injury over the next year.  Have the good sense to stop when the pain begins.

Michael S. O’Hara, PT, OCS, CSCS

In an effort to get back into shape, Monica added some stadium step running to her fitness program.  She went to the high school stadium and made twenty trips up and down the bleachers.  The initial sessions went well but after the first few weeks her knees started aching and the pain began to interfere with activities of daily living.  Monica tried some anti- inflammatory medications and ice but neither produced any relief.  She recently arrived at our physical therapy clinic for some help with her knee pain.

Running stadium steps is a demanding exercise activity that will produce a strong metabolic response.  Unfortunately, stadium steps are too stressful for most people.

Risk/Reward Ratio of the Stadium Steps
shutterstock_385922764For deconditioned individuals, stadium steps fall on the risk side of the risk reward ratio.  Most overweight and “out of shape” fitness clients have tight and weak hips.  They are inefficient in the skill of decelerating their body down the stairs and that skill deteriorates as they fatigue.  They need to use training methods that reduce orthopedic stress and limit biomechanical overload.

Stadium steps are a high level fitness activity.  It is the calculus of mathematical learning.   Deconditioned and overweight individuals need to start with basic algebra before venturing into quantum physics.  The better approach is to get fit first and then add stadium steps to your workout after you have improved strength, body composition, and mobility.

Run hills instead.  I have switched many stadium stepping physical therapy patients to running up and walking down hills.  It is a more forgiving form of fitness training than stadium steps and the benefits are superior.

Your Inner Gladiator
If you insist on stadium step training, I have some suggestions.  Spend six weeks strengthening your hips.  Most deconditioned folks, sit all day and have poor strength/strength endurance in the hips.  Weakness in the hips permits the knees to collapse inward on your downward bound through the steps.  I like bridges, hip lifts, mini band squats, and walking lunges.  See my recent article and video on my favorite gluteal strengthening exercises.

Foam roll the outside, inside, back, and front of your hips, thighs, and hip rotators.  Most stadium stepping pain patients are a big basket of myofacial restrictions.  They writhe around on a soft roller and look at me like I am crazy.  Restoring the mobility of the fascia that encapsulates the deceleration muscles of the hip will help improve performance.

Run up and walk down, softly.  It is the step descent that causes the biomechanical stress on the muscles and joints.  As you travel down the steps, think about actively engaging the gluteal muscles and decelerating with the hips and not the knee.  The louder the impact on the descent the more likely you are an inefficient decelerator.  Have someone watch you as you travel down the steps.  If your knee collapses inward, you need to get off the steps.
Build up slowly.  Do not start with twenty flights.  Start with three trips and gradually build up your work capacity–once a week is more than enough for most folks.  Find other training modalities that are less stressful.  Being too aggressive with a training program is one of the big reasons people fail with fitness, and it keeps me busy in the clinic.

Monica was, by her own account, twenty pounds overweight.  Her hip mobility was less than ideal and she had prior history of hip pain problems.  She had diminished hip range of motion and limited strength in her hamstrings and glutes.  During assessment of her deceleration skills, Monica tended to land in a collapsed inward knee position.  We had Monica perform a program of mobility and strengthening exercises for both hips and rest from all “cardio” activities.  Her knee pain resolved and she was able to return to a program of fitness training.
-Michael O’Hara, P.T., OCS, CSCS

I recently had the opportunity to hear a presentation on the latest and greatest in running research. The presenters used sophisticated computer software to measure the forces runners created with every foot contact. The variance between runners was dramatic. Some glided along with minimal evidence of foot to ground interaction and others shook the earth. The numbers did not coincide with greater bodyweights or sex. Some of the heaviest individuals ran with minimal impact and some of the more svelte runners were thunderfoots. Men did not necessarily land harder than women. What researchers did find is that high impact runners are far more likely to suffer an overuse injury.

Not everyone has access to force plates to measure ground force reactions, so how do you know if you are a high impact runner? The advice the researchers gave was to listen. The individuals with the hshutterstock_109581608ighest force plate impact numbers were the ones who produced the most noise when they ran on a treadmill. After analyzing over 200 runners, the students and researchers were able to easily predict force plate results based on the noise they heard during the treadmill warm up.

Distance running is a very high-level fitness activity, and you must have all performance parameters functioning at optimal levels to avoid injury. If you fail the treadmill listen test, then work on developing a smoother and less stressful gait pattern. Landing lightly has a big impact on staying healthy and pain-free while running. Take the time to read the February 10, 2016, New York Times article by Gretchen Reynolds, “Why We Get Running Injuries (and How to Prevent Them).”

Click on the link below to read the article:


-Michael S. O’Hara, P.T., OCS, CSCS

The first time I saw someone wearing minimalist shoes was in 2006 at a gym in Chicago.  They were Vibram toe shoes, and I can remember thinking there is no way this will catch on.  Then, minimalist shoes got a big boost in 2009 from James McDougall’s book Born To Run, that extolled the virtues of running barefoot.  In a very short time, the minimalist shoe (no cushioning under the foot) became the rage.  Multiple companies introduced “barefoot style” shoes that were supposed to reduce injuries and restore our hidden ancestral running pattern.  It appears that another abrupt change in running shoe design is underway.  An article by Lindsay Crouse in the February 16, 2015 New York Times* introduces us to the Hoka running shoe.  Ultra cushioned running shoes are coming to a shoe store near you, but let’s not get too excited.

Runners seeking to reduce aches and pains and extend their time on the road spend billions of dollars on shoes every year.  They buy shoes that have been “scientifically designed” to control motion, reduce impact, keep the foot stationary, free the foot from entrapment, and prevent injuries.  You can purchase shoes made of high tech fibers, proprietary inserts, gel padding, and assorted mystery materials.  Despite years of innovation and ongoing design changes, none of it has ever proven to be beneficial in reducing running injuries.

A few years ago, the British Journal of Sports Medicine concluded that sports medicine specialists should stop recommending shoes based on a person’s foot posture.  No scientific evidence supported the practice, and “the true effects” of today’s running shoes “on the health and performance of distance runners remain unknown”.

Thinking About Running?

Distance running is an extremely demanding activity that requires good mobility, superior strength levels, and an appropriate body mass.  If you are sedentary, maybe a little heavier, and have difficulty performing basic squat and lunge patterns, you should begin your quest for fitness with an activity other than running.  Many other exercise modalities can move you toward your fitness goals with a much lower risk of injury.  The best place to start is with a proper Functional Movement Screen evaluation provided by a qualified trainer.  Get stronger, improve your mobility, lose the excess body fat and, only then, consider a gradual introduction to distance running.

Current Runners

Research and the legal system are telling us that running shoe hype does not correlate with real life results.  If you are a runner, the best advice is to use a shoe that feels good and be skeptical of running shoe marketing.  Trust your senses, not the salesman.  Run in the shoes and, if they feel bad, hand them back.  Keep a record of the shoes that make your joints happy and stay with that type of shoe.

*New York Times, February 16, 2015, Forget Barefoot; New Trendsetter in Running Shoes Is Cushioning, by Lindsay Crouse

To read the article, click on the link below:


-Michael O’Hara, P.T., OCS, CSCS

“You can observe a lot by watching.” 

-Yogi Berra

Chris logged 25 to 30 miles a week running on the roads.  He had completed well over forty marathon races and could be found nearly every weekend at a 10 kilometer run.  In March, he started having lower back and then right knee pain during his runs.  He moved off the road and started using a treadmill, but the pain persisted.  He tried switching between biking and running, but the pain did not go away.  After three months of self-treatment, he was referred for physical therapy by his family physician.shutterstock_109581608

The only time Chris had the pain was when he was running.  Symptoms began after approximately ten minutes of running and were particularly painful whenever he had to run downhill.  During his musculoskeletal evaluation, we could not recreate Chris’s pain.   He demonstrated good range of motion, normal strength levels, and he had no neural tension problems.  We put Chris of the treadmill, and after five minutes of running, his problem became obvious.  With every right foot strike the knee collapsed inward, the hip joint fell into extreme internal rotation, and the pelvis dropped.  Chris could not feel his running gait deteriorate, but the changes were glaring.  Ten minutes of running on the treadmill in front of the mirror, and he was convinced.  We both knew what had to be fixed.

All parameters of fitness must be at optimal levels to run distances and stay injury free.  Managing tens of thousands of repetitions of joint loading on a daily basis can easily create tissue overload and pain symptoms.  The first sign that a runner is heading toward a pain problem is when his or her running gait starts to deteriorate.  Forty thousand strides a week with excessive internal rotation and not enough hip extension will eventually take a toll.  The good news is that nearly all gait changes are detectable by simply watching how you run on the treadmill.

You do not need a computer with infrared sensors or force plates in your shoes.  You just need a big mirror.  Position the treadmill facing a mirror.  You need to be able to see your feet hit the treadmill when you run.  Start up the treadmill and work up to your training tempo. Keep your eyes open and look for these problems.  Be patient as many of the worst problems only show up after muscles start to fatigue.

Valgus Knee

If after foot strike the knee rolls inward during the stance phase, you have a problem.  For many runners this deficit can be extreme.  Distance running with valgus knees earns you the early knee replacement medal.

Vertical Displacement

Efficient runners are smooth runners.  The more you move up and down the more shock you must attenuate when you land.  Runners with poor strength and endurance often start out smooth and finish bouncy.

Unequal Stride Length

As fatigue sets in, one leg moves well and the other starts to exhibit a stride restriction.  It is not uncommon to witness a 20% decrease in stride length.  Stride asymmetry causes all sorts of tissue tension problems in the lumbar spine and pelvic girdle.


This covers all of the head and torso positional changes:  The head leans to one side, shoulder rotation is full on one side and absent on the other, one side of the pelvis is up and the other down.  Watch the finish of any 10 kilometer run.  Nearly everyone has some tilt.

Most recreational runners do not like to pay attention to any aspect of their training.  Their time on the road is a form of mental relaxation or mediation.  Many people who run for exercise actually hate running, and they watch television while on the treadmill to counteract the boredom.  My suggestion is to spend some portion of your training evaluating how well you are moving.  Stop swearing at Chris Matthews and Bill O’Riley while you run and do something that will actually help improve your performance.  Be more mindful of your gait and make corrections before the pain starts.

Chris was able to return to running after three weeks of manual therapy and corrective exercise.  He has set up a mirror in front of his home treadmill and reports the results have been revealing.

-Michael O’Hara, P.T., OCS, CSCS