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“Static assessment of movement-related injuries may lull a chiropractor into a secondary diagnosis.  There is no substitute for watching patients move.”
- Common Sense

Running is a common trigger for recurrent lower extremity pain. The majority of running-related injuries are due to the repetitive nature of the sport. Patients are often unable to recognize why this activity causes pain and are even more baffled by how one sport can contribute to so many different injuries at different times.  It is our job as evidence-based chiropractors to recognize the underlying factors related to a patients’ condition.  The list of potential contributors to running injuries is complex.  Fortunately, a new paper provides an objective way to assess these deficits and start resolving your patient’s problem.

Patients suffering from lower extremity pain often adopt a familiar faulty running gait.  Learn three simple ways to identify and correct that problem now.

From the video, you can identify several characteristic findings that predispose runners to lower extremity overuse injuries. There are many movement compensations that patients adopt due to their body’s inability to maintain optimal form. Bramah et al. (2018) identified ONE MAJOR possible mechanical defect that patients acquire.

This study identified a number of global kinematic contributors to common running injuries. The contralateral pelvic drop appears to be the variable most strongly associated with common running-related injuries.” 

Findings from this study suggest that most running injuries are secondary to hip instability.  However, not many patients will come into to your office and say their hips are weak.  Identification and correction of this deficit may provide long-lasting relief for runners.  Let’s take a closer look at this deficit; including three evaluations and related management strategies to help our patients recover more quickly and permanently.


3 Simple Ways to Assess for Hip Instability


The Hip Lag Sign is performed with the patient in a side-lying position, affected side up. The clinician stabilizes the patient’s pelvis with one hand while using the other to passively move the patient’s hip and thigh into 20 degrees of abduction, 10 degrees of extension, and maximal internal rotation. The patient’s leg should remain relaxed with the knee bent at 45 degrees. After asking the patent to hold their leg in this position actively, the clinician releases support. The test is positive if the patient is unable to maintain this position and the foot drops more than 10 cm. The Hip Lag Sign demonstrates high sensitivity (89.5%) and specificity (96.6%) for hip abductor tendon injury.


2. Single Leg Stance (Trendelenburg)

The Trendelenburg test is performed by having the patient cross their arms over their chest and lift one leg at a time, while the clinician observes for pelvic drop or knee valgus. The presence of an “uncompensated” pelvic drop when performing the Trendelenburg maneuver suggests gluteus medius weakness. Long-standing weakness may result in a “compensated” response of lateral trunk flexion over the stance leg or moving the ipsilateral arm out to the side. The sign may be more noticeable during a single leg squat or 6-inch step-down.


3. Single Leg Squat

Begin with the patient standing on the affected leg, without support. Have the patient squat three times, returning to a fully upright position between each repetition. The patient should squat as low as possible, stopping for any pain, weakness, or significant loss of balance. The clinician will assess for the presence of a Trendelenburg sign, knee varus/valgus movement, foot pronation, or poor balance. Repeat on the opposite leg. Findings will identify weak links in the kinetic chain, especially hip abductor weakness and foot hyperpronation.

Runners operate in a world where only one foot at a time touches the ground. When the foot is contacts the ground, hip musculature supports global body posture. Weakness or incoordination of the hip stabilizers manifests as un-leveling of the pelvis, valgus knee stress, and compensations at the foot and lower back. Incompetent hip muscles cause an overload of tissues from the foot to the lumbar spine. This is why different people may suffer different diagnoses while sharing the same deficit.


“Injured runners demonstrate contralateral pelvis drop as key finding during running.  In fact, for every 1 degree of pelvic drop there was an 80% increase in the odds of being injured.” (1)

“The most frequently injured sites including the knee, foot, and lower leg, with incidence rates reported of around 50%, 39%, and 32%, respectively. Less common injury sites include the ankle and lower back, as well as the hip and pelvis, with incidence rates ranging from 4% to 16%, 5% to 19%, and 3% to 11%, respectively.”   

Of all running-related injuries, the most frequently cited injuries include patellofemoral pain (PFP), iliotibial band syndrome (ITBS), medial tibial stress syndrome (MTSS), Achilles tendinopathy (AT), plantar fasciitis, stress fractures, and muscle strains.” (1)

After we watch our patients run and perform the tests as mentioned above, it’s time to fix the problem. When hip stability is an issue, we must be diligent in our educational process to explain the benefits of a home-based strengthening program. Rehabilitation takes time and the commitment is not always embraced by busy patients; however, it is our job to inspire compliance. Prescribing the ChiroUp Hip Abductor Weakness protocol is a great place to start. For a PDF of this version specific to running injuries download this LINK.

runners with pain

Hip stability is a significant player to in the injury of runners. Make sure to become proficient with the Hip Lag Sign, Trendelenburg, and Single Leg Squat tests to evaluate patients for hip abductor weakness. If there is weakness, be sure to provide the necessary exercises and patient education to help patients heal quickly and hopefully prevent future injury.

One reliable resource for practical information on gait abnormalities is thegaitguys.com. They have a plethora of information on everything you need to know about running injuries. Motion Palpation Institute also hosts seminars on the assessment and treatment of gait dysfunction. If you are looking to improve your evaluation and hands-on skills, there is no better seminars or teachers. A list of their courses can be accessed HERE. Also, be sure to check out the ChiroUp 15 minutes to excellence webinar on hip abductor weakness.

Still not a member of ChiroUp? That’s okay. Thanks for reading our blogs; and we would love to hear from you! What topics are you most interested in learning more about? What is the most significant time-sink in your day that you would like to fix? What opportunities do you see for chiropractic in the future? To be innovative, we need help. Our team listens to every question and discusses every comment sent our way. Thank you in advance for your feedback.

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  1. Christopher Bramah MSc, MCSP, Stephen J. Preece PhD, Niamh Gill PhD, and Lee Herrington PhD, MCSP Is There a Pathological Gait Associated With Common Soft Tissue Running Injuries? The American Journal of Sports Medicine (2018) 1–9 DOI: 10.1177/0363546518793657

About the Author

Dr. Brandon Steele

Dr. Brandon Steele


Dr. Steele began his career at The Central Institute for Human Performance. Dr. Steele has trained with experts including Pavel Kolar, Stuart McGill, Brett Winchester, and Clayton Skaggs. He has been certified in Motion Palpation, DNS, ART, and McKenzie Therapy. Dr. Steele lectures extensively on clinical excellence and evidence-based musculoskeletal management. He currently practices in Swansea, IL and serves on the executive board of the ICS.

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