In the previous post (Part 1), I talked about the contribution of the position of our pelvis on our ability to run properly. Muscles cannot fire properly if we are in an anterior or posterior pelvic tilt. While this is a significant contribution, a lot of runners have more often felt afflicted from the sideways contributors of running. This manifests most commonly as IT-band syndrome, but can also manifest as knee, ankle, foot, and pelvis problems.

Just like our legs can go forward and backward, they can also move side-to-side as well as rotate about their vertical axes internally and externally. This is due to the shape of our hip joint: the round head of the femur fits into the cup-shaped depression of the pelvis, called the acetabulum. Our shoulders work with a similar ball-and-socket joint however, the head of the humerus is not as pronounced of a “ball” as the head of the femur and the glenoid cavity is more of a flat edge than a rounded depression. Generally speaking, the shoulders favour mobility over stability and the hips favour stability over mobility. Which means that unfortunately for us, if our pelvis is not stable and balanced, then our bodies will compensate quickly to become more stable. If our legs that hit the ground running are not balanced, then we will be more likely to develop pain.

Remember how I said a leg can move side to side, as well as rotate about its axis? The muscles in our legs can therefore, be classified into 4 groups:

• muscles which abduct the leg at the hip (move away from the mid-line of the body)
• muscles which adduct the leg at the hip (move toward the mid-line of the body)
• muscles which externally rotate the leg at the hip
• muscles which internally rotate the leg at the hip

There are multiple actions of the muscles involved in these 4 different movements, all of which overlap in different ways. For example, the gluteus medius abducts and internally rotates, whereas the piriformis externally and internally rotates, depending on whether the hip is already flexed or extended (flexed: leg is moving forward, extended: leg is moving backward). When comparing what the lateral/medial muscles do, while some of it may appear to be redundant, each muscle has a slightly different contribution to locomotion. This means that if one muscle is left to do the work of several muscles, it can result in a lot of pain and movement problems.

Let’s take a closer look at this by analyzing some of the most common lateral hip problems:

IT-band syndrome – legs are hitting the ground in an externally rotated manner, causing the vastus lateralis head of the quadriceps muscle to become enlarged and rub on the band of fascia that runs from the pelvis and connect the tensor fasciae latae (TFL) muscle to the tibia, above the knee joint. This means the hip external rotators are doing too much work and the hip internal rotators are not doing enough work. Oftentimes, the gluteus maximus is also weak and not firing. The pelvis has to find stability in other muscles, and if the TFL is doing the work instead, then this can pull the legs into external rotation. This also means the muscle is short and tight and pulling on that long tendon tightly. Ouch! All of the muscles involved in our walking gait need to be strong.

What can cause IT-band syndrome? 

• Poor running posture
• Unbalanced resistance training program
• Insufficient flexibility
• Flat arches/running with feet pronated
• Improper shoes for gait/feet
• Lack of support from the gluteus maximus

Piriformis syndrome – quite similar to IT-band syndrome in that, many of the same muscles involved are imbalanced similarly. The difference is that piriformis syndrome can cause a different type of pain, due to the piriformis compressing the sciatic nerve. It can have the exact same symptoms as sciatica, the difference being that the problem does not originate from a lumbar disc bulge compressing the nerve but rather, from one deep gluteal group muscle doing more work than it should be. The sciatic nerve exits the lumbar spine to innervate all of the muscles of the back of the leg all the way to the foot; it is the longest nerve in the body. In most people, the nerve passes under the piriformis muscle but in some people, it passes through the muscle.The piriformis grabs on to the femur to prevent lateral dislocation. When the gluteus medius is strong, the piriformis muscle doesn’t need to work as much.

The piriformis grabs on to the femur to prevent lateral dislocation. When the gluteus medius is strong, the piriformis muscle doesn’t need to work as much. As we discussed before, the piriformis can externally rotate the femur when the hip is in extension but it can also internally rotate the femur when the hip is flexed.

What can cause piriformis syndrome?

• Weak glute med/glute max
• Anterior pelvic tilt (see part 1 of this topic)
• Hyperextended knees
• Tight hamstrings
• Poor running posture
• Flat arches/running with feet pronated
• Improper shoes for gait/feet

Knock-knees: running with knocked knees (knees turning inward toward the midline of the body) can cause a host of problems for the knees, but again, this problem lies in the hip muscles. The adductor group is too strong and short, and the abductor group is too weak and long. The result is the forces from running (& walking) can cause pain in the medial aspect of the knee, but can also cause the lateral aspect of the knee to become less stable. This can even allow the patella to track more medially and may contribute to patellofemoral pain syndrome. There is a great video and explanation on this website from a physiotherapy group.

Bow-legs: the opposite deformation of being knock-kneed, the knees turn outward from the midline of the body. When looking at a person with bow-leggedness, their legs mimic a taught bow shape, such as in archery with a bow & arrow. In this case, the muscles which abduct the hip are too strong and short, and the muscles which adduct the hip are too long and weak. This can cause pain in the lateral aspect of the knee, and cause the medial aspect of the knee to become less stable. Again, this may also lead to patellar tracking problems.

If left untreated, any of the above mentioned problems can also lead to patellar subluxation or dislocation. Pain directly behind the knee cap is a sign that patellofemoral syndrome might be happening. If you suspect any of these abnormalities, get yourself properly assessed by a physiotherapist. Preferably, one who runs!

Things to keep in mind when running:

• Always work to correct postural imbalances – this not only affects how you stand, but how you move and how efficient your biomechanics are performing –> greater efficiency, less energy expended, the longer you can go!
• Observe your running posture – are you leaning forward slightly?
• How fast is your footstrike? Foot turnover should be 180 steps/minute. If your footstrike is too slow, the lower body musculature fatigues more quickly, being more likely to allow your body to fall out of alignment. Use momentum to keep you moving, rather than having your muscles burn through your energy before you are ready to stop.

Now that we have gone into detail about common abnormalities, let’s talk about appropriate training. Remember: stretch the areas which are too tight and strengthen the areas which are too weak. Here are some strengthening exercises for the muscle groups we talked about today:

Goal: strengthen hip abductors

• Side-lying hip abduction
• Standing resistance band hip abduction (long band or a loop band)
• Side steps with resistance band (can be a long band in a “Y” shape, or a circular shaped band)
• Standing cable hip abduction (personally, I don’t lift my leg as high because I avoid hiking my hip up)
• Lying down cable hip external rotation

Goal: strengthen hip adductors

• Side-lying hip adduction
• Squeeze a ball between the knees while on the floor or seated
• Standing resistance band hip adduction
• Standing cable hip adduction
• Lying down double cable adduction (my personal favourite but hard to find the proper cable machine for it)

Goal: strengthen hip gluteus maximus and quadriceps

• Glute bridge (works only the glute max, not the quadriceps)
• Squats (works rectus femoris head of quadriceps preferentially)
• Forward lunges (works hip internal/external rotators in maintaining balance and stability; works vastus medialis head of quadriceps preferentially)
• Step ups (vastus medialis)
• Side step ups (works hip internal/external rotators in maintaining balance and stability; works vastus lateralis head of quadriceps preferentially)

Here are some stretching exercises for the muscle groups we talked about today:

Goal: stretch hip abductors

• Seated gluteus medius/minimus stretch
• Lying gluteus medius/minimus stretch
• Seated piriformis stretch
• Lying piriformis stretch

Goal: stretch hip adductors

• Standing side lunge hip adductor stretch
• Seated adductor magnus stretch
• Kneeling side lunge hip adductor stretch
• Lying wall groin stretch