Low back pain and asymmetry.

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Do oarsmen have asymmetries in the strength of their back and leg muscles?
IF these oarsmen were more symmetrical would they not be in pain?

From the study below:
"Patterns of asymmetry of muscle activity were observed between the left and right erector spinae muscles during extension, which was significantly related to rowing side (P < 0.01). These observations could be related to the high incidence of low back pain in oarsmen."

Here we have a supported study of asymmetry and injury/pain. This is what we have been saying (asymmetry matters) in the last few days with our posts on asymmetry. This study eludes to a finding that strength can test normal and symmetrical, but EMG activity can show patterns of asymmetry that can result in problems/pain.

Have you ever rowed? I mean truly rowed, in a shell, on the water, not on land or on a Concept 2 rower? It is just not the same, especially if you have an unilateral asymmetrical loading arc, like an oarsman pulling from port or starboard. I have rowed on the water just like this, briefly, one summer in a camp for young teens. I rowed on my home town course, on the World famous Royal Canadian Henley Regatta. I was the 2nd seat, starboard, in an 8 man shell. 8 oars in the water, 8+1 guys, one oar a piece, alternating port and starboard. I was behind the stroke. I hated it. Perhaps the hardest thing I had ever done sport wise to that point, largely because this dude setting the pace was jacked on caffeine, or something else, I think. No one works harder than rowers if you ask me, they are some of the fittest athletes in the world. Why? because it is a whole body effort.
Ok, enough of the fluff.

Now imagine rowing like this for many years in high school, college and/or competitively. Forcefully pulling on one oar, across an arc of pull out one side of the boat, thousands of times a day for many years. If that isn't something that will develop asymmetry I do not know what might. Oarsman are under near constant high end effort pushing and pulling loads (push with the legs, pull with the arms). There are few, if any, sports with such high end constant effort than rowing.

From the Parkin et al study:
"The aim of this study was to establish whether asymmetry of the strength of the leg and trunk musculature is more prominent in rowers than in controls. Nineteen oarsmen and 20 male controls matched for age, height and body mass performed a series of isokinetic and isometric strength tests on an isokinetic dynamometer. These strength tests focused on the trunk and leg muscles. Comparisons of strength were made between and within groups for right and left symmetry patterns, hamstring: quadriceps ratios, and trunk flexor and extensor ratios. The results revealed no left and right asymmetries in either the knee extensor or flexor strength parameters (including both isometric and isokinetic measures). Knee extensor strength was significantly greater in the rowing population, but knee flexor strength was similar between the two groups. No difference was seen between the groups for the hamstring: quadriceps strength ratio. In the rowing population, stroke side had no influence on leg strength. No differences were observed in the isometric strength of the trunk flexors and extensors between groups, although EMG activity was significantly higher in the rowing population. Patterns of asymmetry of muscle activity were observed between the left and right erector spinae muscles during extension, which was significantly related to rowing side (P < 0.01). These observations could be related to the high incidence of low back pain in oarsmen."- Parkin et al.

Extra sauce:
I "caught a crab" many times when a novice oarsman and was nearly vaulted out of the boat on one fatal event. A crab is the term rowers use when the oar blade gets “caught” in the water. It is caused by a momentary flaw in oar technique and the paddle end of the oar is pulled into the depths instead of skimming just below the surface. Catching a crab has happened to anyone who has ever rowed. A crab may be minor, allowing the rower to quickly recover, or it may be so forceful that the rower is ejected from the boat as the handle end catches the oarsman under the arms lifting them out of the boat.

J Sports Sci. 2001 Jul;19(7):521-6.
Do oarsmen have asymmetries in the strength of their back and leg muscles? Parkin S1, Nowicky AV, Rutherford OM, McGregor AH.

Asymmetry seems to matter with pathology.

image credit: https://commons.wikimedia.org/wiki/File:PSM_V46_D167_Outer_surface_of_the_human_brain.jpg

image credit: https://commons.wikimedia.org/wiki/File:PSM_V46_D167_Outer_surface_of_the_human_brain.jpg

When you have low back pain, your gait is apt to be asymmetrical

...And that is just what this study showed. It looked at 82 right leg dominant folks with slightly less than 1/2 of them havong low back pain. The folks with lower back pain spent more time on their non dominant leg at the beginning of a gait cycle and on their dominant leg at the end of it. Not surprising that they wanted to find a more stable base or center their COP over the weight bearing foot, especially in light to the fact that the back has such poor cortical representation.

Sung PS, Danial P. A Kinematic Symmetry Index of Gait Patterns Between Older Adults With and Without Low Back Pain. Spine (Phila Pa 1976). 2017 Dec 1;42(23):E1350-E1356. doi: 10.1097/BRS.0000000000002161.

Want to bring out gait pathology? Add something new into the mix...

image source: https://en.wikipedia.org/wiki/Walking

image source: https://en.wikipedia.org/wiki/Walking

We have talked about bringing out compensations and asymmetries in gait patterns by adding a novel stimulus to the exam, like having the client/patient put their hands over their heads, or close their eyes. Here is yet another tool for your toolbox: having the client walk backwards.

Both forward and backward walking share pattern generation control circuits in the brainstem, providing similar (though reversed) kinematic patterns. Backward walking requires different muscle activation sequences which can highlight subtle gait asymmetries, particularly in individuals that have cortical impairment (like the kids with cerebral palsy in this paper) or perhaps people with more subtle cortical impairments, like cerebellar dysafferentation from abnormal joint and muscle mechanoreceptor input and integration. Don’t believe us or what the study says, try it on yourself! It can be a humbling experience : )

In part, the study concludes: “The observed spatiotemporal asymmetry assessments may reflect both impaired supraspinal control and impaired state of the spinal circuitry.”

The next time you are having a difficult time seeing something in an evaluation, or are trying to bring out an asymmetry, in addition to your other tricks, have them walk backwards.

Cappellini G, Sylos-Labini F, MacLellan MJ, Sacco A, Morelli D, Lacquaniti F, Ivanenko Y. Backward walking highlights gait asymmetries in children with cerebral palsy. J Neurophysiol. 2018 Mar 1;119(3):1153-1165. doi: 10.1152/jn.00679.2017. Epub 2017 Dec 20.

Adding strength to compensations and asymmetry.

FootNotes, with The Gait Guys.

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The CNS runs the show. Compensations are real, they are a calculated response, they are meaningful adaptive protective behaviors. Adding strength to a compensation makes them even more real, plastic, permanent. Fix the problem. Adding random strength is juvenile thinking. Letting one's client load/train/lift when in pain is juvenile (read below). Once we realize adding load to the problem can be helpful or hurtful, we are on the right path, we are winning. But it takes a deep understanding of how to add load safely, wisely, so that our client can benefit. We must try to understand adaptive behaviors, we must try to understand why our client's CNS made the choices it did.
Now, imagine a client with ankle pain, and resultant ankle dorsiflexion/ankle rocker loss. Now, imagine what their gait will look like as well with that premature heel rise and everything that adapts from that premature heel rise. Now, read below and understand one way how the CNS adapts. Why? So that the next time one chooses a stretch, mob, flossing, etc to gain a range of motion, without any additional meaningful measures, hopefully they will realize they are likely not addressing the deeper problem. Pushing a range of motion is not the same as safely re-earning a range of motion. Far from it. -Dr. Allen

*Effect of Achilles tendinosis on the agonist, synergist and antagonist muscles. Chang and Kulig

"In addition to the altered control system, the present study also observed an adaptive behaviour, as illustrated by the activity of agonist, synergist and antagonist muscles. This was seen during single-legged hopping, where the contribution from the triceps surae muscle to the plantar flexors was decreased and the co-contraction from the tibialis anterior muscle was also decreased on the involved side in individuals with Achilles tendinosis. This may be attributed to the protective mechanism shielding the already injured tendon from further injury or even rupture (Lund et al. 1991)."- Chang and Kulig

J Physiol. 2015 Aug 1; 593(Pt 15): 3373–3387.
Published online 2015 Jun 30. doi: [10.1113/JP270220]
PMCID: PMC4553058
PMID: 26046962
The neuromechanical adaptations to Achilles tendinosis
Yu-Jen Chang and Kornelia Kulig

This could happen to you if your ankle dorsiflexors get weak.

This could happen to you if your ankle dorsiflexors get weak.

This (read below) is actually a normal compensation. Building strength on this compensation without resolving the anterior compartment weakness can lead to knee pain (or other things). It is why, again, we say that asymmetry and especially asymmetrical compensations, can matter in your client.

"muscle strength asymmetry in the ankle joint may lead to counterbalancing muscle strengthening of the knee joint to maintain the center of body mass."

"It is not only the balance between the agonist and antagonist muscles, but also the balance between the left and the right, and between the proximal joint and distal joint in a weight-bearing position that are involved during exercise. As seen in the university players in this study, the weakening of dorsiflexors due to muscle strength asymmetry in the right ankle joint is thought to cause the strengthening of the extension muscles of the knee joint in order to maintain the center of body movement and stability." - Kyoungkyu et al.

What The Gait Guys have to say about this:

As that foot is approaching the ground, and begins loading, the anterior compartment may not skillfully allow a forefoot loading response and may not protect that anterior ankle mortise joint let alone appropriate and skillful pronation. Ankle dorsiflexion loading may occur too fast and uncontrolled leading to sudden undesirable knee flexion (too much, too fast, too long). After all, closed chain ankle dorsiflexion and knee flexion are deeply paired loading movements. One way to slow down this increased amount of forward tibial progression (ankle dorsiflexion and knee flexion), is to increase the activity of the quadriceps/knee extensors. The compensation of increased knee extension loading will offset the increased knee flexion resulting in improved control the ankle dorisflexion. It is a reasonable compensation, but not one you want to stick around for long or unaddressed. If subtle, and left over time, perhaps even when subclinically presenting, knee pain from increased shear/compression or other mechanical results, may be the first presentation when the true problem is down in the lower region.

Remember, this is about controlling gait and thus center of body mass. This is about not falling over. This is about the central nervous system making necessary adaptations to protect the entire organism, which sometimes means doing anything so as not to fall. Now, just to make this more complicated and fun, imagine that this is a fairly common problem and compensation ON ONE SIDE of the body. So now imagine, the changes in arm swings, maladaptive loading onto the other side, pelvis asymmetry and the list goes on.

Of course, one could just globally add strength to this client, such as more squats, lunges or more deadlifts (instead of a focal intervention at the anterior ankle structures) thus adding another layer of compensation, and perhaps making them feel better, for the time being. Essentially, adding global strength to asymmetry. But make no mistake, this problem is likely to sit here and percolate under the surface with more possible compensations, subtle movement alterations and adaptations, until someone addresses the problem. And remember this, if one does those things long enough, those become a client's new adaptive neuroplastic patterns. Strength first is not always a good first intervention.

J Phys Ther Sci. 2016 Apr; 28(4): 1289–1293.
Effects of muscle strength asymmetry between left and right on isokinetic strength of the knee and ankle joints depending on athletic performance level
Kyoungkyu Jeon, PhD,1 Sungyung Chun, PhD,2,* and Byoungdo Seo, MS, PT3

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4868229/

photo credit: free photos courtesy of Pixabay

The next time they have gait asymmetry, try changing out the insole...

or putting a textured one in there...or maybe putting a some sand or dirt in their shoe...

image credit: https://torange.biz

image credit: https://torange.biz

Textured insoles change (we like to think for the better) proprioceptive input and can improve balance and gait performance, both statically and dynamically. We have seen this in folks with parkinsons (1) as well as stroke (2), though it can be used in the elderly (3), in diabetes and neuropathy (4), as well as healthy individuals (5,6). Changes from postural stability, to changes in anterior/posterior sway, to medial/lateral sway, to step length and height, the research is there.

These results support the hypothesis that enhanced somatosensory feedback to the sensory system, both through the spinocerebellar and dorsal column pathways, as well as the vestibular system, results in an improved motor output (and most likely coordination) of gait.

  1. Qiu F, Cole MH, Davids KW, et al. Effects of textured insoles on balance in people with Parkinson's disease. PLoS One. 2013;8(12):e83309. Published 2013 Dec 12. doi:10.1371/journal.pone.00833

  2. Ma CC1, Rao N2, Muthukrishnan S3, Aruin AS4. A textured insole improves gait symmetry in individuals with stroke. Disabil Rehabil. 2017 Aug 7:1-5. doi: 10.1080/09638288.2017.1362477. [Epub ahead of print]

  3. Annino G1,2,3, Palazzo F2, Alwardat MS4, Manzi V5, Lebone P2, Tancredi V1,2,3, Sinibaldi Salimei P2,6,7, Caronti A2, Panzarino M2,3, Padua E2,3. Effects of long-term stimulation of textured insoles on postural control in health elderly. J Sports Med Phys Fitness. 2018 Apr;58(4):377-384. doi: 10.23736/S0022-4707.16.06705-0. Epub 2016 Sep 15.

  4. Paton J, Glasser S, Collings R, Marsden J. Getting the right balance: insole design alters the static balance of people with diabetes and neuropathy. J Foot Ankle Res. 2016;9:40. Published 2016 Oct 5. doi:10.1186/s13047-016-0172-3

  5. Steinberg N1, Tirosh O, Adams R, Karin J, Waddington G. Influence of Textured Insoles on Dynamic Postural Balance of Young Dancers. Med Probl Perform Art. 2017 Jun;32(2):63-70. doi: 10.21091/mppa.2017.2012.

  6. Collings R1, Paton J2, Chockalingam N3, Gorst T2, Marsden J2. Effects of the site and extent of plantar cutaneous stimulation on dynamic balance and muscle activity while walking. Foot (Edinb). 2015 Sep;25(3):159-63. doi: 10.1016/j.foot.2015.05.003. Epub 2015 May 11.

More asymmetrical thoughts

Again, in this study, like the last we discussed here, we are looking at experienced (and in this case, young) runners; sprinters specifically. Again, they ran relatively short distances (20 meters). More than 1/2 the runners had “large” asymmetries, and they all had asymmetries of some type. Some athletes had injuries and some did not.

There wasn’t a difference in sprint performance over this short distance. This is not surprising in light of the previous paper we discussed; asymmetries seem to worsen over time (Hanley 2018). The level of compensation present (since these are experienced runners) may also be better; the folks that were uninjured having compensation patterns that were more in line with their anatomy, than the injured ones.

  • The asymmetries did not change. Thinking about anatomy, especially with hard deformities like torsions or versions, why would they? You can’t change the stripes on a tiger.

  • Injured and non injured athletes did not differ in asymmetry before or after the study. Again, why would they? We are talking about gait changes (or perhaps compensations). What is significant for one individual (tibial torsion, femoral retroversion, leg length discrepacy) may not be as significant as it for another, depending on the compensation present.

The study concludes “... kinematic asymmetries in the stride cycle were not associated with neither maximal sprint running performance nor the prevalence of injury among high-level athletic sprinters.” Note that they are talking about prevalence of injury, not incidence of injury.

We still think that asymmetry matters...

Haugen T, Danielsen J, McGhie D, Sandbakk Ø, Ettema G. Kinematic stride cycle asymmetry is not associated with sprint performance and injury prevalence in athletic sprinters. Scand J Med Sci Sports. 2018 Mar;28(3):1001-1008. doi: 10.1111/sms.12953. Epub 2017 Aug 15.

Thought experiment on symmetry: Does symmetry always matter?

the short answer is probably not. the long answer is maybe...

This study looked at gait variability asymmetry in small cohort of experienced distance runnners. They measured different variables at 1500, 3000, 5000, 7500 and 9500 m of a 10000 meter run (about 6.2 miles) on a treadmill. Generally speaking, variability was low and athletes were symmetrical for 5 of seven variables measured and assymetry, when present, was in flight time and impact forces Most aththletes were asymetrical for at least one variable as well.

Their conclusion basically said that being asymmetrical in a few variables is not abnormal and not indicative of asymmetrical gait and since many practitioners analyze symmetry (and variability) caution should be exercised when determining the need for intervention.

So what do we think this means?

most likely:

  • these folks were symmetrical with low variability. In other words, when asymmetry was present, it was small

  • some asymmetry, in some parameters, is probably normal...but,it is usually small if it doesn’t matter. Keep in mind these were expreienced, uninjured folks. th results could have been different with a bigger cohort and less experienced runners and thus...

  • The study does not talk about inexperienced runners. Symmetry and/or asymmetry may not be normal for inexperienced runners

  • Results may have been vastly different if the run had been longer. The study did show that variability increased the further along on the run the athlete was.

  • The study was performed on a treadmill, which may not exemplify or highlight asymmetry, as it creates artificial constraints which we have discussed in by us here, here, and here:

  • We think asymmetry matters, particularly when it comes to hard deformities like torsions and versions, which change the biomechanics of that individual extremity and can be a diagnostic tool for future problems

  • perhaps asymmetry is significant in his population of runners on a subclinical basis

Hanley B, Tucker CB. Gait variability and symmetry remain consistent during high-intensity 10,000 m treadmill running. J Biomech. 2018 Oct 5;79:129-134. doi: 10.1016/j.jbiomech.2018.08.008. Epub 2018 Aug 16.

Asymmetry doesn't matter?

Asymmetry doesn't matter?
There were many people jumping on the Usain Bolt "asymmetry doesn't matter" train in the last few weeks after all the discussion on his scoliosis and leg power differentials. Now nothing but silence.
We think asymmetry matters, and we wrote about it all last week.
What if Bolt were just a little more symmetrical ? Would he have been a little faster ? Is Gatlin faster or just more symmetrical ? Lucky race? I bet Gatlin doesn't think so or care, nor does Coleman. LOL. Fuel for the fire. We will stand our ground however.

We are not pointing fingers or picking on anyone, fact of the matter is we love the good debates that have been going on. That is where the learning occurs. We are always happy to be wrong, as long as we leave a debate smarter than when we went in to it.
#crickets #maybeasymmetrymatters

Addendum worth adding here (from comments below):

Eric A Johnson , asymmetry is the law/rule. How much is too much? No one can answer that. But if we drive a patient towards less asymm and they don't have pain, injury incidence reduces, their chronic complaint becomes less of issue or resolves, or if performance improves...... then maybe, just maybe, their asymmetry mattered. #noguarantees #wishwecouldclone #crystalballs

And . . . if Bolt had won, everyone would be just saying that more proof that asymmetry is ok, ignore asymmetries in your clients.
Fact of the matter is, as we said in our post, that asymmetries are the norm, the rule of law, but that does not mean that asymmetries are not an issue in some people and some athletes. When is an asymmetry too much that it poses an injury risk or a performance loss ? No one knows until we can clone people, but there is a tipping point in everyone where it is just plainly too much to risk. That is the point of the discussion.
So, we are glad Gatlin and Coleman beat Bolt. Only because an older guy beat the King are we having this discussion, thankfully. Which is really what matters here, the discussion, instead of defending ones flag because of one journal article that has a big unknown hanging over it.

We have acquired the asymmetry study below.
We hope to have something to share that helps in the asymmetry dialogue. The authors did quote "To the authors’ knowledge, this is the first study to present the magnitude of asymmetry in sprinters with mean maximal velocity >10 ms-1 " So anyone hanging their hat on one study should consider pulling back on the reigns a little before planting their flag. More research needs to be done.

To clarify our stance, since it became clear in the ensuing debate yesterday that our perspective was not well postured, that we are talking about physical biomechanical asymmetries in muscle strength, power, endurance, skill and torsional issues, functional leg length differences, etc. Not performance asymmetries that may result from these asymmetries. We apologize for our lack of clarity, we all at times assume that others we debate with know what angle we are jousting from, hence why debate is good, to clarify all the factors and find some better answers and common (or uncommon) ground.
We also will assume that most of those debating yesterday from the article's perspective, had likely not read the article either since it was just released and is a fee-based paper.

For those wondering, here were the variables looked at:
"The following variables were included in analyses;
step length, step rate, contact time , aerial time, touchdown angle (for the stance leg), knee separation (assessed as inter-thigh angle) at touchdown, lift-off angle, thigh - and knee angle at lift-off (for the stance leg), maximal thigh flexion, range of thigh motion, rear knee flexion at maximal thigh extension, and horizontal ankle velocity (of the lateral malleolus marker for the soon -to -be stance foot) relative to CoM"

Our stance would be, based off our comments previously, if these things were asymmetrical, could driving the client toward greater symmetry, result in better outcome performance. That was and is, our thought experiment.

 

 

This was a dialogue we had recently and we have been messaged on it numerous times. Don't get too rigid in your beliefs, it might come back to bite you (that goes for us too). It is best we all keep our eyes and minds open. Science moves forward, so don't plant your flag so far in the ground that you can't pull it up when the landscape of knowledge moves the frontline further ahead.

Paraphrased:
Research has not yet provided all the answers to all our questions in the study of the human frame. There are plenty of studies we have all found that are flawed, so we are not going to always agree with research, research is a starting place, a foundation work from, but things change and they change fast sometimes . . . . just because something has not been validly proven yet (or disproven) in research doesn't mean it is not going to be nor does that proposed thought not deserve deeper thought . . . learning doesn't stop at the end of the pen of a researcher who may know a little less on a topic than others. Just because there is a published journal article on a topic doesn't necessarily make it a reliable paper or make it law or a template we must all embrace or "forever hold our peace". Challenging the present facts and knowledge doesn't necessarily always make it "bro science" either.
Question everything while working from a present day base of knowledge. And be ok with being called a bro, it can a compliment , sometimes, and sometimes not by those who may be feeling uncomfortable that their belief system may be quivering in uncertainty from some new paradigms in thought.

 

http://www.tmz.com/2017/08/05/usain-bolt-loses-final-solo-100m-race-justin-gatlin/

Podcast 128: Usain Bolt, Plantaris Tears, Arm Swing

Podcast links:

http://traffic.libsyn.com/thegaitguys/pod_128final.mp3

http://thegaitguys.libsyn.com/podcast-128-usain-bolt-plantaris-tears-arm-swing

https://www.thegaitguys.com/podcasts/


Key Tagwords:

usain bolt, plantaris tear, plantaris, sole lifts, heel lift, leg length, short leg, heel drop, shoeque, symmetry, asymmetry, sprinters, scoliosis, tendinopathy, achilles, runners, marathons, running injuries, arm swing

Our Websites:
www.thegaitguys.com
summitchiroandrehab.com   doctorallen.co     shawnallen.net


Our website is all you need to remember. Everything you want, need and wish for is right there on the site.
Interested in our stuff ? Want to buy some of our lectures or our National Shoe Fit program? Click here (thegaitguys.com or thegaitguys.tumblr.com) and you will come to our websites. In the tabs, you will find tabs for STORE, SEMINARS, BOOK etc. We also lecture every 3rd Wednesday of the month on onlineCE.com. We have an extensive catalogued library of our courses there, you can take them any time for a nominal fee (~$20).
 
Our podcast is on iTunes, Soundcloud, and just about every other podcast harbor site, just google "the gait guys podcast", you will find us.
 
Show Notes:

Superficial plantar cutaneous sensation does not trigger barefoot running adaptations.

https://www.ncbi.nlm.nih.gov/pubmed/28728130

Arm swing
http://www.medicalnewstoday.com/articles/173680.php

Usain bolt
https://mobile.nytimes.com/2017/07/20/sports/olympics/usain-bolt-stride-speed.html?referer=

Plantaris tears
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1978447/

Does asymmetry matter ?

Does asymmetry matter ?

There has been some brilliant talk in the socialverse as of late that asymmetry doesn't matter. We believe these dialogues may be contextual for dialogue purposes (perhaps?) and we have no problem with that. I am sure we may approach our patients differently, though restoring pain free function is the goal. We have a problem layering more endurance, strength and power on asymmetry. Sure the client may feel better, but that is just because the threshold of the system is better, maybe. They have better armor, they are more durable, and thus further from the pain line, but the problem is undeniably still there, it is just protected. 
So, why not try to move closer to symmetry, if that gives pain relief, and then build strength, power, and endurance on those cleaner patterns ? Doesn't that make more sense ? One question we have, that science cannot prove (or disprove) is whether greater strength on asymmetry increases risk for injury ? Well, we think so, and we think that if for a given client, that strength and endurance built on a more symmetrical frame is likely to have less risk for injury. But, the verdict will always be out on that until we can clone folks.

We believe that driving toward symmetry much of the time does in fact matter. Is it going to happen 100%?, no, asymmetry is the rule in the human frame. We are talking about not driving deeper strength, power, endurance into an asymmetrical pattern that further puts strain into tissues not designed or apt to be favorable to the organism/joint/limb etc. We are putting together a written piece expressing some of our points of view further. We have found that when we drive our clients towards symmetry we often, not always, have to drive less strength and load into our clients to dampen the pain beast.

Stay tuned . . . .

https://youtu.be/0Jn2CESZ6jw

and what have we been saying?   Gait problems leave clues. Asymmetry is a BIG clue  &ldquo;Asymmetrical lower extremity neuromuscular control is predictive of repetitive stress injury in recreational runners, according to findings presented at the Combined Sections Meeting of the American Physical Therapy Association in February in Anaheim.&rdquo;   http://lermagazine.com/issues/march/years-after-achilles-tear-injured-limb-demonstrates-elevated-knee-loading

and what have we been saying?

Gait problems leave clues. Asymmetry is a BIG clue

“Asymmetrical lower extremity neuromuscular control is predictive of repetitive stress injury in recreational runners, according to findings presented at the Combined Sections Meeting of the American Physical Therapy Association in February in Anaheim.”

http://lermagazine.com/issues/march/years-after-achilles-tear-injured-limb-demonstrates-elevated-knee-loading

Injures induced by running the same direction on an indoor/outdoor track.

We have been seeing, addressing and treating this problem for years, far too many years. There are few things that frustrate us more than coaches and athletes who refuse to alternate their track workouts into the clockwise direction to help avoid the repetitious detrimental training effects of continued and repeated counterclockwise track training. 

Here is a study from 2000 that tends to validate a causal link to our point. The study confirms a statistically significant asymmetrical strength development in the hindfoot invertor and evertor muscle groups. 

Imbalances are a frequent and well known cause of injury.  Consciously driving this asymmetry is the equivalent to purposefully encouraging injury if you as us.  Why anyone would not heed recommendations to balance out workout effects is beyond us.  We encourage road work so that there are no repetitive track banks to negotiate and thus knowingly drive asymmetry.  When weather makes outdoor work an impossibility then days should ideally alternate the flow on the track to counter the direction of the previous day.  And as track event days get closer then the inevitable will occur that you want to simulate race day direction but at least deeply engrained (skill, endurance and strength) training effects in the counterclockwise direction will not terribly risk injury as much as if there had been no training changes and accommodations.

The smaller the track radius the more detrimental the training effects. Frequency and duration of the training further magnifies training effects. A banked track will mute some of the effects but not all of them. 
So why not just reverse the direction of your track training ?  And don’t tell is it is logistically too difficult to coordinate, that is a lame excuse. You are training yourself or your athletes to be better runners, so you should want to reduce risks and optimize training effects. Period.

Shawn and Ivo……… The Gait Guys

Clin J Sport Med. 2000 Oct;10(4):245-50.

Asymmetrical strength changes and injuries in athletes training on a small radius curve indoor track.

Beukeboom C, Birmingham TB, Forwell L, Ohrling D.

Abstract

OBJECTIVES:

1) To evaluate strength changes in the hindfoot invertor and evertor muscle groups of athletes training and competing primarily in the counterclockwise direction on an indoor, unbanked track, and 2) to observe injuries occurring in these same runners over the course of an indoor season.

DESIGN:

Prospective observational study.

SETTING:

Fowler-Kennedy Sport Medicine Clinic, The University of Western Ontario, London, Ontario.

PARTICIPANTS:

A convenience sample of 25 intercollegiate, long sprinters (200-600 m) and middle distance runners (800-3,000 m) competing and training with the 1995-1996 University of Western Ontario Track and Field team.

MAIN OUTCOME MEASURES:

A standardized protocol using the Cybex 6000 isokinetic dynamometer was used to measure peak torques of the hindfoot invertor and evertor muscle groups of both limbs using concentric and eccentric contractions performed at angular velocities of 60, 120, and 300 degrees/sec. Changes in peak torques between the preseason and postseason values were calculated and compared using a repeated measures analysis of variance test. Injury reports were collected by student athletic trainers and in the Sport Medicine and Physiotherapy clinic.

RESULTS:

Primary analysis indicated that the left (inside limb) invertors increased in strength significantly more than the right (outside limb) invertors (p = 0.01), while the right evertors increased in strength significantly more than the left evertors (p = 0.04). A high incidence of lower extremity injury (68%) occurred in this sample of runners, corresponding to an injury rate of 0.75 injuries per 100 person-hours of sport exposure. Although sample size was limited, secondary analysis indicated that strength changes were not significantly different for injured (n = 17) and uninjured (n = 8) runners (p > 0.05).

CONCLUSIONS:

The observed small, but statistically significant, asymmetrical changes in strength of the hindfoot invertor and evertor muscle groups can best be described as a training effect. Altered biomechanics proposed to occur in the stance foot while running on the curve of the track are discussed in relation to the observed strength imbalance. A causal link between strength changes and lower extremity injuries cannot be inferred from this study, but suggestions for further research are made.