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What is Pre-Hab , and how can it help you ?

Cleaning up imbalances in the body before they turn into full- blown injuries is key to running and fitness longevity and the first step when setting exercise or running goals.

Most of us take in our cars for regular oil changes. We may even get our teeth cleaned regularly, but what are we doing to tune before we start  pounding the pavement? That’s exactly what a “pre-hab” visit can do for you. With one evaluation, clients now have a way to increase their performance and prevent injuries before they have a chance to develop.  By slow motion analyzing a clients functional movements and running any imbalances in muscle strength and compensations can be detected.

The beauty of a great therapist is that they see the problem before it manifests. They study the entire biomechanical chain and analyze potential issues before they become an injury.

A good example would be Janet, who comes into the office for knee pain. She has been treated other places with ultrasound, electrical stimulation, ice and some exercises. She has not had much success and becomes frustrated and resorts to using a knee brace and over the counter drugs for the problem. Upon evaluating her  whole biomechanics chain, We were able to find imbalance in one of her hips, which is where the source of the problem is located, even though she has no hip pain. Injuries need to be completely examined to locate the source of the injury, not just where the pain is. Many will keep chasing pain their whole life because they have not had anyone look at them from this perspective.

Instead of rehabbing an injury, In Balance Physical Therapy gives you a Pre-hab routine so you can keep running and training  injury free. They Address any aches and pains you may have by empowering you to take better care of yourself with self-mobilization techniques, Kinesio-taping, and other specific stability and mobility exercises .

These pre-hab evaluations take one hour and look at posture, flexibility, core stability ,strength and functional movements.

This year, do it right and get yourself a pre-hab check-up before you wind up looking for someone to treat an injury. It makes sense and saves you time, money and the anguish of having to stop your training right when you are gearing up for an important event.

In Balance Physical Therapy provides FREE running clinics and screenings to most of the high schools in Miami Dade as well as the running groups FootWorks. One of the bigger teams we cover is a continually growing club in Miami called FDC.

If you would like In Balance Physical Therapy to provide you with a free clinic for your club or group please contact Cathy Accurso at 305 -251-2912 or email at . Check us out to see how we are different at www., You won’t be disappointed !

Cathy Parbst-Accurso, PT, CKTP,FAFS is the the owner of In Balance Physical Therapy. As a former National Duathlon Champion and someone who was ranked 12th in the world as a professional athlete in her sport, she knows what it takes to not only excel in a sport but to prevent the injuries that one may be prone to.

January 19, 2018 0 Comments

Bonking vs. Fatigue vs. Cramping: What You Need to Know


What is bonking and why does it happen?

Bonking, also known as hitting the wall, is a term used to describe what happens when your body runs low on glycogen to burn as a fuel source.

While your body can burn fat directly for energy, it tends to prefer glycogen, as it is easier to burn and more efficient. Thus, when running at marathon pace, some portion of your energy output is going to come from burning glycogen – there’s no way around this.

As your glycogen stores begin to run low, your body recognizes the potential danger and slows the body down gradually to conserve energy.

At this point, you can still run, but your pace will begin to slow unless you increase your effort. However, if you continue, your glycogen stores will get so low that your body will basically shut down and even jogging will be almost impossible.

This is what’s called bonking.

Bonking is not feeling tired; bonking is not an inability to move your legs faster. Bonking is when your glycogen stores get low enough that your brain shuts down your body.

What does it feel like to bonk?

A “true” bonk will almost always result in you not being able to physical run any longer.

You may be able to shuffle and probably walk, but anything that resembles running is likely out the window. More than likely you’ll feel dizzy or light-headed (a result of your brain not getting the glycogen it needs) and some runners feel nauseous.

As you can see, this feeling is a bit different than fading or getting fatigued during the latter miles.

How can you prevent a true bonk?

You have two primary ways to prevent bonking.

First, you can slowly train yourself to burn fat more efficiently as a fuel source. This will enable you to burn less glycogen per mile at your marathon pace.

It’s important to remember that you cannot race a marathon using fat alone as a fuel source. If you run easy enough, sure, but if you’re pushing yourself it’s just not scientifically possible.

You have a few ways you can train your body to be more efficient at burning fat. One is to perform “fasted long runs”, . The other is to include marathon pace training during your long runs.

The second way to prevent a true bonk is to fuel yourself adequately before and during the race.

The trick here is that it’s just as bad to over fuel as it is to under fuel.

Your body can only process a finite amount of carbohydrate per hour (30-60 grams depending on your individual efficiency). If you try to take in more carbohydrates than you can handle, the digestive system starts to shut down and you don’t absorb anything.


How is fatigue different from bonking?

Now that we understand the true definition of bonking, we can start looking at what runners often “mislabel” as bonking – getting tired.

It may seem simplistic, but I think a lot of the struggles marathoners go through when they have a bad race can be attributed to fatigue.

I think we often forget that a marathon is a grueling event, even when you’re well trained. Three, four and even five hours of pounding the pavement is tough on the body and it’s almost always going to take its toll.

And while attributing your struggles to fatigue may sound oversimplified, it’s the first step in targeting the right elements in your training to prevent it from happening again.

What causes “marathon fatigue”?

Fatigue during the marathon is the same as any other race distance. The problem is that it’s magnified by at least twice as much thanks to the distance.

First, you have muscle damage, which can be quite significant during a marathon.

  • Another study concluded that creatinine kinase (CK) damage – a marker that indicates damage to skeletal and myocardial tissue – persisted more than 7 days post marathon while another study confirmed the presence of myoglobin in the bloodstream post marathon for 3-4 days post race.

In short, when you’re racing the marathon, you’re significantly damaging your muscle fibers (see this study for some cool muscle biopsy photos post marathon).

This damage to the muscle fibers reduces their ability to produce the powerful contractions needed to maintain marathon pace effort. It also causes that soreness and dead-leg feeling you get late in a race. If you don’t significantly increase your effort, you begin to slow down.

Second, as you begin to increase you effort to make up for the muscle damage, you begin to produce more lactate (a by-product of anaerobic respiration) which interferes with your body’s ability to clear hydrogen and results in a build-up of acid in the muscles.

Likewise, the more effort you expend, the more you have to rely on glycogen as a fuel source (since it’s the most efficient form of energy). As discussed previously, this signals the brain to slow down to ensure survival, which means the brain is now also sending signals to slow down.

As you can see, this quickly becomes a triple whammy of fatigue that sets you down a path of fading during the final miles.

How can you better prepare yourself?

The challenge of preparing yourself for marathon fatigue is that running the full marathon distance in training is not recommended (due to how long it would take to recover).

So, we need to get creative in training to simulate the fatigue and develop the muscular endurance needed. To accomplish this, we can do two things:

We can implement what coaches call the theory of “accumulated fatigue”. Basically, this means that the fatigue from one workout accumulates and transfers to the next so that you’re always starting a workout or a long run a little tired from your previous training.

This type of training helps your develop the muscular endurance without needing to run the full marathon in training. An example of accumulated fatigue would running a steady run the day before a marathon-specific long run.

Second, using what we know about how muscle fibers work, you can implement specific workouts that are designed to fatigue your legs and muscle and then have you train and run at marathon pace. Some example workouts include:

Tailoring your marathon training to include accumulated fatigue and specific workouts can make a dramatic difference in how you feel during the later stages of the race.


Thanks to the millions of dollars funneled into the sports drink market every year, most runners blame their cramps on dehydration or lack of electrolytes. But, when you look at the research, it’s very clear that only a very small percentage of muscle cramps in runners are caused by fluid of electrolyte loss.

First, as noted by physiologist and MD Tim Noakes1, exercise cramps don’t occur exclusively on hot days. Even swimmers in very cold water can suffer from muscle cramping and there’s little high-quality research linking exercise in the heat to an increased risk of cramps.

In another study2, 43 Ironman athletes who developed cramps during the course of the race were followed. The data showed that neither body weight changes (which can estimate dehydration levels) nor blood electrolyte levels were correlated with suffering cramps during a race.

Finally, A 2005 study published in the Journal of Athletic Training3 had 13 athletes perform a series of exercises done in hot, humid conditions. During one trial, the men were given large volumes of sports drink with extra salt added in, and during the other, no liquids were consumed. Nine of the 13 men still got cramps even in the sports drink trial. Moreover, in the no-liquid trial, only seven men experienced cramps.

So if it’s not dehydration or electrolytes causing cramps, what is?

The cramps you’re likely experiencing during a marathon are called “muscle overloading” or a fatigue cramp.

These occur when the neural mechanisms that are supposed to inhibit muscle contraction are depressed and the chemical and electrical synapses that fire the muscle fibers is enhanced.

But why does this happen during the marathon?

As we just learned, your muscles undergo significant stress when racing. As you get further into the race, the slow twitch fibers you’ve been using start to get tired and you can no longer fire them as efficiently. As a consequence, you start to recruit some intermediate fibers to help maintain pace. Of course, these intermediate fibers require more glycogen and are not as fatigue resistant as slow-twitch, so it won’t be long before you start compensating.

As an example, as your glute muscle fatigues (one of the most important muscles when it comes to generating power from your stride), your leg won’t simply stop working. Instead, your brain tells your muscles, “hey, this glute isn’t getting the job done, let’s fire the calves more forcefully to make up for the lack of power.”

Your calf isn’t nearly as strong or powerful as the glute. Moreover, it’s likely you’ve never trained it to handle this type of stress. As a result, the calf cramps!

How to prevent cramping during the marathon

Now that we understand how muscle fatigue can lead to marathon cramping, how do we go about addressing the issue?

Specifically, how can we simulate the fatigue you’ll experience 20 miles into a marathon?

  1. Improve form and posture

Just like you need to perform core and injury prevention work to stay healthy, it’s important you perform specific strengthening exercises that target the mechanics that commonly deteriorate late in a race.

For example, if you tend to suffer from calf or quad cramps late in a race, you’ll want to perform exercises, drills and stretches that focus on improving your hip extension and posture (two very common culprits of bad form that leads to cramping).

Not only will this reduce many of the limitations that may be preventing you from generating proper hip extension, these exercises will help you improve your muscular endurance and ability to generate proper hip extension late in a race when you’re tired.

  1. Simulate late race fatigue in the gym

Bodybuilders have long employed a technique called split training, where they train the same muscle group twice per day. The goal is to use the morning session to lift heavy and maximize the recruitment of muscle fibers and thereby fatigue the muscles. They then come back for a second evening session where they use lighter weights and higher reps to blast their fatigued muscles. This stimulates tremendous growth.

We can use this principle and tweak it to better train our running-specific muscles to withstand the rigors of the full marathon distance.

First you perform a morning session that consists of heavy weights and low repetitions. These will be mostly compound exercises that focus on the hips, hamstrings, glutes and lower back. Our goal is to recruit maximum muscle fibers and fatigue the muscle.

You’ll then come back for an evening session and perform very running-specific hip, hamstring, glute and lower back exercises designed to train those muscles while they are tired.

This specific training should simulate the fatigue you experience late in the marathon race and prepare the muscle groups most responsible for a breakdown in running form.


It’s also important to remember that these causes of marathon failure don’t occur in isolation. I am very certain all runners experience some amount of each in every race they run.

That means you shouldn’t ignore any element in preparation for your next race.

However, most runners find that it’s one particular factor that’s causing the most trouble.

Now that you better understand the science, the causes and appreciate the difference between all three you can better plan your training for your next race.

Bonking vs. Fatigue vs. Cramping: What You Need to Know Written by  Jeff Gaudette

To prevent these from happening get a “Peak Performance Running Evaluation” To analyze your running form, strength and range of motion that is needed to be an efficient runner and not break down

. At In Balance Physical Therapy we perform a Peak Performance Running Analysis that identifies any of your imbalances and weaknesses . We give you a specific plan to help you achieve that balance independently.  We video your running from multiple perspectives and coach you on improving your form. Teaching you how to decrease the ground reactive forces, so you can not only be a better runner but also more efficient and injury free!

Our Peak performance Running Analysis is the first step in preparing your body to take on any running goal you may have or to take your running up a notch in performance.

Whether you are a beginner or an elite runner the Peak Performance Analysis is a great way to really learn about your body and improve your running.

Call 305-251-2912  to schedule your evaluation and get you running strong!

March 27, 2015 0 Comments

3 Most Useless Gym Exercises for Runners (And What to do Instead)

Most runners understand the value of strength work for improving performance and staying healthy. If you haven’t jumped on the bandwagon yet, maybe some peer-reviewed research can help sway your opinion.

studies have shown as much as 4% increase in running efficiency and a 3.1% improvement in 5k time with strength training alone. Even better, studies show improving hip strength virtually eliminated the onset of IT band syndrome and runner’s knee.

Thus, the question isn’t should you add strength training to your running schedule, but what exercises are most effective for runners.

With an endless variety of machines and exercises to choose from, is it possible you’re wasting your time with exercises that seem like they would help your running, but in reality offer little running-specific benefit and may even contribute to injuries? Judging from what I’ve seen in the gym, most runners are.

To help you make the most of your time spent strength training, here are the three exercises to avoid and more effective, running-specific alternatives.

Quad extension machine

The quad extension machine targets a singular muscle group, in one range of motion, that doesn’t mimic any of your proper running mechanics. Even worse, this exercise puts a tremendous amount of stress on your patella tendon, which can easily become inflamed and result in patella tendonitis, an injury that accounts for almost 5% of all running-related injuries.

Many runners think the motion of this exercise will help them drive their leg forward with less effort. Unfortunately, that’s not how running mechanics work.

During the recovery phase of the gait cycle, your heel rises towards your butt to create a better lever for your leg to move forward – a shorter lever means less work needs to be done by the hip flexors and quads.

Once the leg is forward, your shin unfolds in preparation for contact with the ground. This is the movement the quad extension mimics. However, while actually running, this movement requires almost no effort from the quad muscle. Since the hamstring is contracted to bring the heel towards the butt, all the hamstring has to do is relax and the leg drops back into a neutral position. Very little activation of the quad is needed. As such, the quad extension machine is useless and potentially harmful.

Do this exercise instead

The single leg squat.

Stand with your arms extended out in front. Balance on one leg with the opposite leg extended straight leg forward as high as possible. Squat down as far as possible while keeping your other leg elevated off of floor. Keep your back straight and supporting knee pointed in the same direction as the foot supporting. Raise your body back up to the original position until the knee and hip of the supporting leg is straight. Return and repeat.

If you’re an advanced runner, you can perform this exercise with an uneven weight on one side (either with a barbell, like a traditional squat, or while holding a weight in one hand).

Not only does this target your quad muscle in a more running-specific way, since it mimics the stress on your quads, knees and hips as you enter the stance phase of the gait cycle, but research also shows it engages your hip stabilizer muscles, making this a more dynamic movement that can prevent knee injuries.

Hamstring curl

Like the quad extension, the hamstring curl machine targets a singular muscle group in one range of motion that is not correlated with how the hamstring is used or activated during the gait cycle.

Again, most runners believe that the hamstring curl will make them more efficient at bring their heel towards their butt during the recovery cycle. This isn’t surprising, since this is the exact range of motion reproduced during this exercise.

However, bringing the heel towards the butt actually requires very little activation of the hamstring. Electrographic research suggests it is as little as 7%. The movement of the heel towards the butt is aided by the stretch-reflex generated during hip extension (the amount your leg travels behind you during your stride). This is why the faster you run, the closer your heel will get to your butt without trying to.

Do this exercise instead

Cable drive back.

With your foot or heel attached to a cable machine, stand facing the structure that the cable is attached to. Balance on one foot (it’s ok to hold onto another object for balance) and bring your leg slightly in front of you. Drive backwards with your foot in the band. Focus on generating the movement from your glutes and hamstrings. Slowly bring the leg back up and repeat.This exercise mimics and strengthens the hamstring and the glutes in the exact motion they are engaged during the running gait.

As your foot touches the ground, ideally directly under your center of mass, the hip and hamstring work to drive the leg backwards. This is what creates explosive speed and is when the hamstring is most activated. Thus the exercise strengthens the hamstring in the exact motion and firing pattern you’ll use during your stride.  Plus, it’s dynamic and also recruits the hips and glutes.

Hip abductor machine


Unfortunately, this isn’t the case.



Do this exercise instead


Wrap a theraband around your knees while standing with your feet shoulder width apart. Walk to one side, taking short, 2 to 3 foot steps, for 10 steps then walk to the other side for ten steps.  see video :

The sidestep displayed a statistically significant difference in EMG signals in both the gluteus medius and gluteus maximus muscles compared to the TFL. This exercise will improve running-specific hip strength without risk of aggravating the IT band.

Make the most out of the precious time you have to spend at the gym or strength training by understanding how running biomechanics work and targeting the movements needed to help you improve form, run more efficiently, and stay injury-free.

Article by Runners Connect : Jeff Gaudette




Cathy Accurso PT, CKTP

January 3, 2014 0 Comments

A Scientific Look at How to Lace Your Running Shoes to Reduce Injury and Increase Comfort

Most biomechanics and physiology researchers focus their efforts on big topics like injury, performance, and health. These research papers are usually centered on fundamental issues like impact, pronation, and oxygen consumption.

But, fortunately for us, a few researchers take the time to investigate some of the lesser but still important topics.

For example, a while back, we looked at some scientific studies on chafing and blistering in runners—a nontrivial topic for many of us!

Today, we’ll look at another of those “little details”: how should you lace your running shoes?

how to lace running shoes

The science of how you should lace your shoes

One particular research group, headed by Marco Hagen at the University of Duisberg in Germany, has published several papers on just that question. The first of these papers, published in 2008, looked at the biomechanics of twenty distance runners moving at 8:00 mile pace on a treadmill under a variety of different lacing conditions. Data on impact force, pronation, and the pressure under the sole of the foot were collected.

All runners wore the same shoe, a Nike Air Pegasus, but laced several different ways. As do most running shoes, the Pegasus has six eyelets on each side, plus a seventh at the top which is slightly offset from the rest. The first three lacing conditions involved tying the shoes (with the normal 6-eyelet cross lacing) with different tightnesses, “weak,” “normal,” and “tight,” as perceived by the subjects in the study. After that, the researchers tested some additional lacing patterns, including an incredibly lose two-eyelet lacing (using only the first and second eyelets, a three-eyelet lacing (using the first, third, and fifth), and a seven-eyelet lacing using a “heel lock” loop on the final shoe eyelet, as depicted below.

Normal lacing and seven-eyelet heel lock lacing

The results showed that shoes tied tightly reduce pronation velocity and, more importantly, reduced impact loading rates. As you might have guessed, the looser and less comprehensive lacings using only two or three eyelets resulted in increased impact loading rates and pronation velocities. Pronation has not been reliably tied to injury rates, but impact loading rates have, so a reduction in loading rate by simply tightening your shoes is noteworthy.

A tight lacing also reduced localized pressure on the outside of the foot, likely by pulling the heel deeper into the shoe’s insole. However, there was a downside—the runners consistently reported the tight-laced condition as being one of the least comfortable. However, Hagen et al. found that the seven-eyelet “heel lock” lacing at a normal tightness was just as effective at reducing impact loading rates, pronation velocity, and plantar foot pressure as the standard six-eyelet lacing tied tightly.

In a later study, Hagen and his colleagues conducted a similar experiment, however, this time they added a measurement of the pressure on the top of the foot. This is an important step forward, as increasing the tightness of your laces increases pressure over the top of the foot, including the navicular bone and the extensor tendons that cross the ankle. While these areas are not injured very often, injuries to the navicular and extensor tendons can be very bothersome.

Using a similar experimental procedure, Hagen et al. tested fourteen male runners using only the normal six-eyelet lacing, the seven-eyelet heel lock, and a variant of the heel lock in which the sixth eyelet is skipped. The results showed that the two lacings that utilize the seventh eyelet result in lower pressures on the top of the foot without sacrificing any significant amount of stability in the foot’s contact with the insole of the shoe.

The special heel lock which skips the sixth eyelet (pictured below) was particularly effective at reducing pressure on the top of the foot.


Seven-eyelet heel lock lacing and special heel lock lacing which skips the sixth eyelet.

One lacing style I was disappointed that Hagen did not investigate is “ladder lacing” (sometimes called “Lydiard lacing” after Arthur Lydiard, who advocated its use in some of his books in the ‘60s and ‘70s).

Ladder lacing is a technique which (purportedly) reduces pressure on the top of the foot by not allowing the laces to cross over the middle of the metatarsals. I would be interested to see whether this preserves shoe stability while reducing pressure on the top of the foot.

Image courtesy of

Additionally, many shoes today come with straps instead of eyelet holes. It’s unclear whether these provide any additional stability or advantages compared with regular eyelets. As always, there’s more research to be done!

Final notes

  • For the average runner, Hagen’s work highlights the importance of lacing up your shoes snugly. Most runners would probably be well-served by using a heel-lock lacing to increase the stability of their shoe and decrease their impact loading rates.
  • If you are prone to injury on the top of your foot, or if you find tight or high lacing uncomfortable, try using the special heel lock, as it has all the benefits of the regular heel lock or tight normal lacing, but with less pressure on the top of the foot. And lastly, don’t forget to double-knot your shoes!


1. Hagen, M.; Hennig, E. M., Effects of different shoe-lacing patterns on the biomechanics of running shoes. Journal of Sports Sciences 2009, 27 (3), 267-275. 2. Nigg, B., The Role of Impact Forces and Foot Pronation: A New Paradigm. Clinical Journal of Sports Medicine 2001, (11), 2-9. 3. Davis, I. S.; Pohl, M. B.; Hamill, J., Biomechanical and Anatomic Factors Associated with a History of Plantar Fasciitis in Female Runners. Clinical Journal of Sports Medicine 2009, (19), 372-376. 4. Hagen, M.; Homme, A.-K.; Umlauf, T.; Hennig, E., Effects of Different Shoe-Lacing Patterns on Dorsal Pressure Distribution During Running and Perceived Comfort. Research in Sports Medicine 2010, 18 (3), 176-187.

December 29, 2013 0 Comments

How to Prevent Running Injuries: Using Prehab to avoid Rehab

Anyone who has ever had a running injury (and let’s face it that probably includes most of you) will be familiar with receiving a list of strengthening exercises designed to help get you back to 100%. Most therapists will tell you (myself included) that the runners who recover the quickest tend to be those who find/make time to do their rehab exercises.

Unfortunately, once runners are back on the road, that’s when the strengthening exercises normally stop.

In a world where free time is more and more precious, the idea of sacrificing running time in order to perform some conditioning exercises is normally met with resilience. Before long your efforts return once again to either building up weekly mileage so you can achieve that PB or simply getting out of that front door as quickly as possible because running is what you love to do.

The thing is, those exercises that helped you get over your injury—they could well help you avoid a repeat injury; in other words, rehab becomes prehab.

To become a better runner , just running is not enough

Increasing weekly mileage or volume plays a major part in improving race performance especially in marathons. Exercise physiologist and author Dr. Jason Karp found a strong correlation between training volume and performance in male and female qualifiers for the U.S. Olympic Team Trials marathons, as running expert Matt Fitzgerald points out in his article Are You Running Enough Miles?

However, as Dr. Karp also points out, at least 50% of runners deal with at least one injury a year, and 25% of runners are injured at any moment in time.

Constantly trying to increase your volume may come at a price and just running more does not seem to help prevent it.

Given that injury is the number one cause for delays in training and failure to achieve goals, is there anything else we should be doing that will allow us to reap the benefits of running more without inviting injury?

Volume, frequency, intensity

A commonly quoted reason for injury is doing too much, too often, too soon. If we accept that increasing volume is necessary to improve performance, maybe we can avoid injury by simply just avoiding sudden increases in how often we run (frequency) or how quickly we run (intensity)?

Though there is much logic to this argument, there is surprisingly little evidence to support it.

The research that has been done either contradicts itself or fails to provide any significant conclusions due to the methods used. In an attempt to group together and analyze valid research, Nielson et al. (2012) carried out a systematic review (meta-analysis) to explore the relationship between running-related injury and training volume, intensity and frequency.

Thirty two relative studies were analyzed, involving 24,066 runners of varying experience. The conclusions of the review are summarised below. (For an in depth look, see the article written by Physiotherapist Tom Goom here.

  • Volume. The review supported the idea that running more miles a week than what your body is used to may increase risk of injury but stated that there is very little conclusive research on how much of an increase in weekly volume is safe.
  • Frequency. Though studies reveal a “U-shaped” curve with regards to frequency, i.e. a higher injury risk from training once per week and 6-7 times per week (compared to running 2-5 times per week), the variety in results lead to the conclusion that it is not possible to determine the specific role of running frequency with regard to injury.
  • Intensity. The relationship between average training pace and injury risk is conflictive in research results with the majority of studies finding no significant relationship.

All very inconclusive. Though on a clinical level it may seem that injured runners have often made sudden changes in volume, frequency or intensity, many have not. Something else seems to be missing from the equation.

Strength training and injury prevention

Could strength training be the missing ingredient? Could prehab be better than rehab? Is there any evidence that adding strength training to our weekly running program reduces risk of injury?

A second systematic review this time by Laursen et al. (2013) entitled “The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials” may provide us with some encouraging results.  Twenty-five relative studies were involved, with a total of 26,610 participants and 3464 injuries. The following conclusions were reached:

Strength training can reduce sports injuries to less than a third and overuse injuries by almost 50%.

Though it is important to point out that this review was not specific for runners, the link between running and overuse injuries means it does have interesting implications in favor of runners adding strength training to their weekly program in order to reduce the risk of injury.

The review also highlighted the benefits of proprioception training (exercising in an unstable environment to stimulate development of coordination of joint motion and acceleration) and “no beneficial effect for stretching” (presumably ‘static’ stretching). For a more in depth analysis of the review, Running Research Junkie Craig Payne takes a look here.

What type of strength training do runners need?

If I said “just go out there and do something you don’t normally do,” you would probably stop reading this article. We like rules. We like explanations.

In rehab, strengthening exercises are prescribed with the purpose of “correcting” an “undesirable” movement pattern and/or promoting a change in your running gait that will reduce the likelihood of you suffering the same pain, maybe even help you run more efficiently.

In reality, the benefits we get from strength training are often not for the reasons originally sought in the exercise prescription phase.

A good example is assigning hip abduction exercises (clams, lying leg lifts to the side, fire hydrants, etc.) to a runner suffering from knee pain and exhibiting hip valgus (thighbone angled inwards in relation to hip) and femoral internal rotation when running.

As Greg Lehman (one of the guest lecturers on the Runners Connect Improve Your Running Form course) points out, sometimes we do see the strengthening program being followed by a reduction in hip valgus/femoral internal rotation but often we do not. Sometimes there is no mechanical change but the original pain is no longer present.

In my opinion, the mechanism behind modifications in pain or movement is not understood enough that we can afford to always favor some exercises and reject others. Given the dominant role of the brain and central nervous system in producing both pain and movement, maybe introducing the body to variety of movement is key.

But aren’t “functional” exercises the only ones that really help us become better runners?

In pursuance of variety, watch out for trainers telling you that certain exercises are not “functional” enough to benefit you as a runner.

Yes, specificity (performing exercises that mimic as closely as possible the movement you are trying to improve) has been shown to play a major part in improving performance, but this does not in my opinion mean that exercises failing to meet the “functional” criteria are useless or detrimental.

The plank is a great example of an exercise that is often dismissed these days as “non-functional” and not suitable for runners.

When running your body is vertical, so a horizontal plank has no value. I disagree. All exercises can have a carry over. The plank strengthens the trunk and hip muscles. Using its many variations it can be used to enhance coordination, balance and mobility. Greg Lehman defends the plank wonderfully in his article Postural correction and changing posture. Can we treat our patients like puppets?  and also reminds us that performing a few planks a week will not cause us to somehow become so rigid that our spines will stop moving when we run.


Adding strength training to your weekly training program could well reduce your risk of injury by 50%. Think prehab as opposed to rehab.

As far as which exercises to choose, think variety!

Challenge the brain by selecting exercises that encourage you to learn new movement. Coordination, proprioception, balance, skill, agility – all of these are vital to runners and will not be improved by just running more.


Practice movements that involve moving the body in all three planes of movement. Though running ultimately involves moving forwards (what we refer to as the sagittal plane – see picture), to promote variety you also need to ensure you are practising movement in the side (frontal) plane and rotational (transverse) plane.. Before long your efforts return once again to either building up weekly mileage so you can achieve that PB or simply getting out of that front door as quickly as possible because running is what you love to do.


At In Balance Physical Therapy we do Prehab with our Peak Performance Running Analysis: the most in depth evaluation a runner can have : video analysis of running and functional movements, postural analysis, strength and flexibility analyzed to find asymmetries in the body that can lead to injuries as you increase intensity and mileage.

Call NOW for you Peak performance Running Analysis. 305-251-2912  WE are the running experts.

Article by Matt Phillips of Runners Connect


1. Karp, J.: Training Characteristics of Qualiﬁers for the U.S. Olympic Marathon Trials (2007). 2. Fitzgerald, M.: Are You Running Enough Miles? (2013). 3. Nielsen et al.: Training errors and running related injuries: a systematic review (2012). 4. Goom, T.: Injury prevention in runners – Skimpy Research (2013) 5. Lauersen at al. “The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. 6. Payne, C.: Strength Training for Runners to Prevent Injury (2013) 7. Lehman, G.: 8. Martin, B.: Strength training and running technique 9. Fitzgerald, J.: Developing Running Coordination (2011)


December 17, 2013 0 Comments

Injured and worried about Losing Running Fitness? Read this

how much will taking a few days off hurt my running fitness

Article by Jeff Gaudette  of runners connect

How much will taking a few days off from running hurt my fitness? It’s one of the most common questions I get from runners struggling with an injury, fighting the flu, or hesitant to take a much needed rest from training. As runners, we are all paranoid about taking a few days off, generally thinking it will ruin our months of meticulous training.

As a coach, I am not immune to being frightened by this irrational fear. While I was training for the NCAA championships while in college, I had a swimming accident that left my left shoulder separated and required a visit to the hospital to get it back in place. The doctors told me I needed to take a few days off to let the shoulder heal. Not wanting lose any precious training time, I strapped my left arm tight across my body using a combination of saran wrap and duct tape and went on a 12-mile run the next morning. Luckily, I didn’t suffer any lingering affects from the imbalances I created by running with one arm. However, I wanted to share this story with you to demonstrate that I write this article with the deepest understanding of how hard it can be to listen to science and understand that a day off isn’t going to end your hopes of running as fast as you’ve dreamed.

When we look at the effects of taking time off from running, we have to analyze the detraining from two perspectives: (1) your metabolic systems such as aerobic fitness, threshold and VO2 max; and (2) your structural systems such as your muscles and neuromuscular coordination (how fast and efficiently your brain can tell your body to perform and execute a specific movement).

Effect of detraining on the aerobic system

Because VO2 max is one of the best measurements of a runners physical fitness, I will use it as the baseline to compare the effects of detraining on your aerobic system. To be brief, VO2 max is an individual’s maximum ability to transport and use oxygen during exercise.

Recent studies show that there is little reduction in VO2max for the first 10 days following inactivity in well-trained athletes. It is prudent here to mention that all of these guidelines assume you are a decently trained runner, having trained consistently for a 4-6 month period. Beginner runners will lose fitness at a slightly faster rate since they have a smaller base of fitness.

After two weeks of not running, studies show that VO2 max decreases by 6%. After 9 weeks VO2 max drops by 19% (sorry, I couldn’t find any data on 3-8 weeks post inactivity). After 11 weeks of no running, Studies demonstrate that VO2 max falls by 25.7% from peak physical fitness.

So, as you can see, from an aerobic standpoint, you have very little to worry about if you have to take a break from running for two weeks or less. This is very important for those runners that need to take a hiatus because of a small injury or are nervous about taking downtime after a long training segment. A 6% decline in VO2 max can be made up with one or two weeks of solid training.

While percentages are fantastic, what do those numbers really mean for runners? Let’s use an example of a 20 minute 5k runner. A 20 minute 5k runner has a VO2max of roughly 49.81 ml/kg/min (estimated using a formula). After 2 weeks of no running, the 5k runner would lose 6% of his VO2 max, which would be 46.83 and would now be in 21:05 shape, according to most estimates.

After 9 weeks of no running, the same 20-minute 5k runner would now be in 24:00 minute 5k shape. After 11 weeks of no running, our poor running friend would be in 25:30 shape.

Effect of detraining on the structural system

While the reduction in aerobic fitness has been tolerably studied in an applicable manner, the effect of detraining on specific running muscles has been harder to find. However, the little research that does exist about detraining in general proposes that the most dramatic reduction in fitness occurs within a 10-28 day window. Before and after this window, detraining from a structural perspective isn’t severe.

What does this mean? After 7-10 days of not running, you will lose some muscle power and coordination, but not enough to totally derail your goals. With a few specific workouts such as hill sprints, you’ll be back to your pre-detraining levels before you know it. If your break from training is longer than two weeks, than you’ll have a little bit to make up before you can get back to personal best shape.

What does it all mean?

Research shows you shouldn’t be too worried about losing significant fitness if your break from running is less than two weeks.

You’ll lose some conditioning in your aerobic system and muscles, but pre-inactivity fitness will return quickly. Again, this assumes that you have built a healthy and consistent base of training of 4-6 months prior to taking time off. It’s not the end of your career if you haven’t been training for this long; it simply means that the reduction in fitness will be slightly more pronounced.

After two weeks of not training, significant reductions in fitness begin to occur and you’ll have about 2-8 weeks of training (depending on the length of inactivity) ahead of you to get back to your previous level of fitness.

Basically, here is an easy to follow form chart:

By no means am I suggesting that taking time off from running is an enjoyable experience. However, sometimes it’s inevitable or for the best in the long-term. I hope this article answers all your questions in a practical yet scientifically supported way. Please feel free to comment and share with your running friends.

Now that you know that a few days off, how do you adjust your training when you need to take time off? Here’s an exact outline on how to return to running after injury, sickness or missing training.


December 5, 2013 0 Comments

The latest research on the effectiveness of aqua jogging and 3 scientifically supported tips to help you get the most out of your deep water running Published on June 12th, 2012 Written by: John Davis

By John Davis

Many of my recent articles have been about various ways to prevent injury. But unfortunately, our best efforts are sometimes not enough, and we get injured anyways. When you’ve run too far, too fast, or too much and you’ve done some damage to your body, you’ve got to let it heal. But runners are notoriously tenacious and defensive about their fitness. They don’t want to lose what they worked so hard for! It’s this attitude that often gets them into trouble in the first place. But more to the point, if you have suffered an injury that is going to require some time off, you are probably going to want to do something to maintain your fitness. Among the most popular methods is aqua jogging, sometimes also called deep water running. Today’s article looks at some of the science behind how aqua jogging is done and whether it can be an effective exercise during rehabilitation.

Cross training vs complete rest


Studies on the effectiveness of aqua jogging


Aqua jogging and heart rate


How to make the most of aqua jogging workouts




Recommendations for better aqua jogging results



References   1. Butts, N.; Tucker, M.; Greening, C., Physiologic responses to maximal treadmill and deep water running in men and women. American Journal of Sports Medicine 1991, (19), 612-614. 2. Reilly, T.; Dowzer, C. N.; Cable, N., The physiology of deep-water running. Journal of Sports Sciences 2003, 21 (12), 959-972. 3. Killgore, G. L., Deep-Water Running: A practical review of the literature with an emphasis on biomechanics. Physician and Sportsmedicine 2012, 40 (1).

December 1, 2013 0 Comments

Why You Shouldn’t Worry About a Bad Night of Sleep the Night Before a Race

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Photo: We examine the research on sleep and performance to demonstrate how science has proven the idea that the night of sleep before a race doesn’t matter, why we feel like it does, and how to combat it:






As the team gathered together in the morning for our shakeout run, I sheepishly told my coach about my lack of sleep and how I feared I’d ruined my chances of running well. He responded: “Don’t worry about bad sleep the night before a race; what matters is your sleep two nights before the race.”

I was a little skeptical. That advice seemed like an old wives’ tale. But then he told me the story of how he qualified for the Olympics as a college Junior, running a personal best in both the preliminary and final round of the steeplechase, all without sleeping a wink the night before the race. That convinced me I was going to have a great performance and I immediately put my sleepless night behind me and ran great that day.



The impact of no sleep on physiological markers

A 2007 review paper by Thomas Reilly and Ben Edwards at the Research Institute for Sport and Exercise Sciences sifted through a variety of studies on the impact of sleep and performance. The data they collected from a myriad of studies suggest that while mental cognition was lessened, physiological markers of endurance performance were surprisingly stable – even after a few days worth of poor sleep.


Lack of sleep and actual performance

While raw physiological data is the backbone of exercise science, it sometimes doesn’t translate to race day performance. In the end, what every runner should be most concerned about is whether these findings are going to have a measurable impact on their actual performance.

Turns out, the data supports this as well.

In one study, Dutch researchers had 10 men do all-out 20-minute cycling time trials. The control group was allowed to sleep as normal while the other group arrived at the research lab at 11 p.m., and were not allowed to sleep until they had completed the time trial at 1 p.m. the following afternoon.

The control group covered an average of 7.68 kilometers during their 20-minute cycling time trial. Surprisingly, the no sleep group performed almost exactly the same: they covered an average of 7.62 kilometers, and physiological measurements, including average heart rate, were also nearly identical.

Why does it feel harder on no sleep



This is demonstrated quite nicely in the above mentioned study on Dutch cyclists. The researchers also had both groups estimate how far they had ridden during their time trial. The control group guessed, 7.26 kilometers, pretty close to their actual output.  However, the sleepless group estimated only 6.51 kilometers – almost a full kilometer short.

What does this mean for you?




A version of this article I wrote originally appeared at

author — Jeff Gaudette  Runners Connect

November 29, 2013 0 Comments

Benefits of Hill Sprints for Beginner Runners

For those relatively new to regular running, the notion of introducing maximal effort hill sprints is often met with concern over the possibility of overtraining and encouraging injury.

And yet, including one or two weekly hill sprint sessions into your training may well be safer than just knocking out long distances on flat ground.

The strength training stimulus that hill sprints provide is thought to play a major role in reducing susceptibility to injury. What’s for sure is hill sprints increase the power and efficiency of your stride, enabling you to cover more ground with each stride using less energy. Still worried about hill sprints? Read on…

Hill sprints for neuromuscular fitness

In the article Components Of A Training Plan, we looked at the importance of including different types of runs to your training in order to improve pace. We noted that running fitness has three components which although inter-related are stimulated by different types of training: aerobic fitness, neuromuscular fitness, and specific endurance.

Hill sprints are an example of a type of training that enhances neuromuscular fitness. In other words communication between the brain and the muscles. Working at maximal or near-maximal levels challenges the nervous system to activate huge numbers of motor units and fire them quick enough to generate high force whilst resisting fatigue.

Stride frequency, stride length and resistance to fatigue all depend on the efficiency of communication between the brain and muscles and are all vital for production of optimum power, efficiency, and resistance to fatigue. Though long runs are important for developing aerobic fitness, without sufficient neuromuscular fitness form can deteriorate, inefficiency, and fatigue set in, all of which are often associated with injury.

Hill sprints allow you to push your body and generate high leg turnover (cadence) without actually running that fast. This is of great significance as maximum speed work on flat ground is often associated with injury such as hamstring strains. Running uphill is also thought to stimulate form improvement by imposing demands that flat running does not.

For example, though lifting the knee high is not something you should consciously attempt during your flat runs, being forced to do it by a hill could well help pave the way for the natural, unconscious development in knee raise that you will experience as your strides become more powerful. Likewise, hill sprints demand a lifting of the toe (ankle dorsiflexion) prior to landing, something that again is associated with power generation and increase in stride length.

In case “maximal or near-maximal levels” has struck fear into anyone’s hearts, we are only talking about duration of approximately 8-12 seconds. Your introduction to hill sprints may be just a couple of these with a 2-3 minute rest in between. But how steep a hill do we need?

Hill gradients

The gradient of a hill is the vertical distance (climb) expressed as a percentage of the horizontal distance traveled. A 100% gradient is therefore where the climb is equal to the horizontal distance traveled, also known as a 1:1 slope. A 10% gradient (1:10) on the other hand has a climb equal to 10% of the horizontal distance traveled. Grade should not be confused with angle. As we can see in the diagram below, a 100% grade is only a 45o angle.


Grades and Degrees (Source: Wikimedia Commons)

The Guinness Book of World Records lists the world’s steepest road as Baldwin Street in Dunedin, New Zealand, with a gradient of 38% (1 in 2.86) at its steepest section. Needless to say, where there is a challenge there is a race, and indeed every September thousands of people turn up to take part in The Baldwin Street “Gutbuster,” 400 metres including ascent and descent, the current record of 1 minute 56 seconds set in 1994.

As we can see in the photos above, 38% is pretty hardcore. Generally speaking, hill sprints use gradients between 6% (1:16.5) and 25% (1:4). Treadmills can be useful in discovering what a gradient like that feels like but these days most GPS watches conveniently give gradient information.

Incorporating hill sprints into your week

  • For novice runners, the first session of hill sprints should be just one or two 8-second sprints on a 6 to 8% gradient.
  • Recovery time needs to be sufficient to allow the same distance to be achieved in each sprint. This will vary according to the runner; it may be the time it takes to walk back down the hill, maybe 2-3 minutes – whatever it takes in order to allow maximal effort for each sprint.
  • It is also vital not to jump too soon into several sets as the explosive maximal effort employed during those 8 seconds places a great amount of stress on the muscles, tendons and ligaments.
  • Also, it is very important that hill sprints be preceded by a suitable dynamic warm up such as the Lunge Matrix followed by a 1 to 2 mile easy pace warm up on flat ground. A cool down run at easy pace is also advised.
  • Two sessions a week will be sufficient and gains are normally rapid. The number of sprints performed in each session can typically be increased by 1 or 2 every week. Once you are doing 10 sprints each session (twice a week), you could increase the duration of the sprints to 10 seconds.

Again, on paper this may seem little but the increase in demand will be considerate. A month or so after this, choose a hill or section of the hill with a greater gradient, say 10%.  A month later, progress to 12 second sprints, etc.

Here is a cool video of James Carney (13:30 5k runner) performing explosive hill sprints in Boulder, Co.


Hill sprints can increase stride power, build leg strength and increase running efficiency, all of which potentially decrease susceptibility to injury. Have a go, just remember to follow the gradual progression outlined above and take it slow.

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November 29, 2013 0 Comments

How Your Casual and Work Shoes can Contribute to Your Running Injuries

Runners spend a lot of time worrying about the shoes that they wear for their workouts and races.  They’ll try on a dozen different trainers at a running shoe store, searching for the perfect shoe that will keep them running healthy.  But often, they don’t pay much attention to their casual shoes or their work shoes—the ones they’re wearing for the 14 or so waking hours a day that they aren’t running.

But these shoes can be just as important as the ones you run in, and a poorly-fitting or restrictive shoe that you wear for work or for fashion can cause plenty of problems with your running, even if you’re in a great running shoe when you train.

casual shoes running injuries


High heeled shoes

Some of the worst offenders when it comes to unhealthy casual footwear are women’s fashion shoes, with high heels being the most well-known troublemaker.

High heels have a well-established history of being harmful to your feet, as described in a 1994 scientific review article by Francesca Thompson and Michael Coughlin.

According to Thomson and Coughlin, as a shoe’s heel becomes higher, pressure increases dramatically on the forefoot as your weight is shifted forward from your heel to the ball of your foot.  This effect is particularly strong when heel height is over two inches, as it often is in many fashionable boots and high heels.

Narrow, pointed toe boxes are another problem with many casual shoes.  Compounded by the fact that many narrow-toed shoes also have very high heels, which only put more pressure on the forefoot, your toes end up being crammed together, likely increasing your risk of developing several foot injuries that can affect your running.

Too small, too risky

Thomson and Coughlin cite studies showing a significant increase in the prevalence of bunions, hammertoes, and neuromas in women (who are vastly more likely to wear high-heeled, narrow-toed shoes), but not men, after the age of 20.  Their opinion is corroborated by that of Carol Frey and Neil Roberts, two doctors who authored a 2002 article on the foot injuries associated with poorly-fitted fashion shoes.

Frey and Roberts describe a survey of 356 women between 20 and 60 years old which found that 80 percent reported substantial foot pain while wearing their shoes, and that a full three-quarters had some type of foot deformity, like a bunion, neuroma, or hammertoe.

Tellingly, almost 90 percent of the women in the survey who suffered foot pain wore shoes that were too small for their feet.

The women as whole wore, on average, a shoe that was half an inch too narrow for their foot, while the small percentage of women who did not suffer from foot pain or foot deformities wore shoes that were closer to the actual size of their foot—less than a quarter-inch of a difference.

Men’s shoes

While women’s shoes are infamous for having absurdly high heels and impossibly narrow toe boxes, men aren’t immune from problems caused by poorly-fitted casual or dress shoes either.

Many men’s dress shoes feature the same kind of unrealistic pointed-toe shape that’s found on women’s flats and high heels, and the traditional hard sole that can be found on leather shoes is very unforgiving when it comes to support.

A very clever 1995 study examined forces in the hip joint with a variety of shoes directly through an implanted force measurement device.  One intrepid elderly man who was scheduled to undergo a hip replacement volunteered to have a force transducer implanted into his artificial hip, allowing biomechanical researchers to examine how wearing different shoes affected the forces inside his body. Though most types of shoes, including running shoes, hiking boots, and clogs, didn’t function much differently…

Hard leather Men’s dress shoes resulted in a marked increase in force at the hip (and presumably everywhere else in the leg) when the subject was walking.

And given that softer surfaces underfoot can reduce the peak levels of pressure on the bottom of your foot, we should expect that wearing a hard leather dress shoe would result in increased localized pressure and pain in your feet.

A few steps for achieving comfort

When it comes to the types of shoes you wear in your daily life, you don’t always have complete freedom.

  • If you work in an environment which demands snappy dress, your shoe choice is obviously constrained.  But you should do your best to find shoes that fit you well, feel comfortable, and don’t put unnecessary stress on your foot.
  • Women in particular should avoid excessively high heels and narrow toe boxes, trying to keep most of their shoes with heels under two inches.
  • Taking care to make sure your shoe is actually wide enough for your foot will also pay off.  Even though you may be forced to wear uncomfortable shoes for work or fashion reasons, you should still try to limit the time you spend wearing them.
  • Thomson and Coughlin describe how women in New York City wear athletic shoes while walking to work, carrying their high-heeled dress shoes with them until they arrive.  You can also take steps to make your shoes kinder on your feet, like adding an over-the-counter orthotics to a dress shoe with a hard leather insole.

If you do have the ability to wear whatever shoes you like, try to spend most of your time wearing comfortable, supportive shoes.

The best testament on what to wear probably comes from people who spend a lot of time on their feet: next time you’re at the doctor’s office, check what the nurses (who spend hours on their feet every day) usually wear—more often than not, it’s a running shoe or a cushioned, supportive sandal like Crocs.

Comfortable casual and work shoes may not be the most stylish, but they will do a good job of keeping your feet comfortable!

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1. Thompson, F. M.; Coughlin, M. J., The high price of high-fashion footwear. Journal of Bone and Joint Surgery 2008, 78, 1586-1593. 2. Frey, C.; Roberts, N. E., Problem Shoes, Problem Feet: What to Tell Women About Footwear Recommendations on diagnosis, treatment, prevention. Women’s Health in Primary Care 2002, 5 (11), 682-691. 3. Bergman, A. G.; Kniggendorf, H.; Graichen, F.; Rohlmann, A., Influence of shoes and heel strike on the loading of the hip joint. Journal of Biomechanics 1995, 28 (7), 817-827. 4. Tessutti, V.; Trombini-Souza, F.; Ribeiro, A. P.; Nunes, A. L.; Sacco, I. d. C. N., In-shoe plantar pressure distribution during running on natural grass and asphalt in recreational runners. Journal of Science and Medicine in Sport 2010, 13 (1), 151-155.

November 29, 2013 0 Comments