1. The Art of Movement Less Pain and More Fun Running and Walking With Proper Biomechanics Mark Cucuzzella MD FAAFP Associate Professor of Family Medicine West Virginia University Lt Col USAF Reserves

2. “If athletes were given less care and more thought, the doctors might come up with some original ideas on why illness persists, why injury doesn’t clear up. If more non-physicians-- podiatrists and physiotherapists for instance-- could be induced to lend their ideas and talents, we might see a completely new approach to sports medicine.” Dr. George Sheehan 1975

3. “Many patients do not want to know very much about their injuries or illnesses- they simply want to be made well. Athletes on the other hand, want to know not only exactly what is wrong, but also why it happened. The first major difference in treating injured athletes is a need for greater communication and patient education The second difference is a need for more complete and comprehensive rehabilitation- a subject all but ignored in most medical training programs.” Dr. James Garrick 1981

4. copes with impact and takeoff --extends from spine to foot

5. Foot-strike: Start Of The Running Cycle Foot touches ground - slightly ahead of the center of mass. (Ideal under center of mass) Foot touches ground - slightly ahead of the center of mass. (Ideal under center of mass) This will minimize the braking effect and help to carry linear momentum forward This will minimize the braking effect and help to carry linear momentum forward The knee flexes, the tibia internally rotates, the ankle plantar flexes, and the subtalar joint pronates The knee flexes, the tibia internally rotates, the ankle plantar flexes, and the subtalar joint pronates Pronation helps absorb some of the compressive shock forces, torque conversion, adjustment to uneven ground contours, and maintenance of balance Pronation helps absorb some of the compressive shock forces, torque conversion, adjustment to uneven ground contours, and maintenance of balance It is necessary to have a certain amount of pronation to disseminate the energy of the foot-strike. If there is too little or too much pronation injuries may occur It is necessary to have a certain amount of pronation to disseminate the energy of the foot-strike. If there is too little or too much pronation injuries may occur

6. Mid-support to Takeoff Foot transforms from a mobile structure into a rigid lever that can support several times the body weight Foot transforms from a mobile structure into a rigid lever that can support several times the body weight Subtalar and midtarsal joints lock Subtalar and midtarsal joints lock Shape of the bones and the tension on the ligaments give foot rigidity Shape of the bones and the tension on the ligaments give foot rigidity The supination of subtalar joint forms a rigid lever for forward propulsion The supination of subtalar joint forms a rigid lever for forward propulsion Series of events: the knee joint extends, the lower extremity rotates externally, the calcaneus inverts, the midtarsal joint locks Series of events: the knee joint extends, the lower extremity rotates externally, the calcaneus inverts, the midtarsal joint locks Traditional teaching- Propulsive force thrust backward and downward from a combination of hip extension, knee extension, and ankle plantar flexion Traditional teaching- Propulsive force thrust backward and downward from a combination of hip extension, knee extension, and ankle plantar flexion Period ends with heel rising upward into takeoff Period ends with heel rising upward into takeoff

7. Follow-through Period Starts when the foot leaves the ground -initial floating period Starts when the foot leaves the ground -initial floating period Pelvic rotation - allows additional travel Pelvic rotation - allows additional travel Flexion of the knee (lifting ankle)- this shortens the lever allowing for greater forward velocity Flexion of the knee (lifting ankle)- this shortens the lever allowing for greater forward velocity Many ways to move leg forward- but what is most efficient Many ways to move leg forward- but what is most efficient As the next foot strike occurs- ideally the foot will be moving backward with a velocity equal to the forward movement of the trunk As the next foot strike occurs- ideally the foot will be moving backward with a velocity equal to the forward movement of the trunk

8. Stride Length And Stride Frequency Over-striding can be energy costly due to the foot-strike deceleration Over-striding can be energy costly due to the foot-strike deceleration Stride frequency should remain constant: elite runners 180-200 footstrikes/min Stride frequency should remain constant: elite runners 180-200 footstrikes/min What changes is stride length What changes is stride length

9. Arms Synchronous with the action of the legs- play vital role in running and are not just merely used for balance Synchronous with the action of the legs- play vital role in running and are not just merely used for balance Help the legs in propelling the body upward, thus providing lift Help the legs in propelling the body upward, thus providing lift Aid in achieving a constant horizontal velocity- reduction in energy cost Aid in achieving a constant horizontal velocity- reduction in energy cost Less vigorous arm swing better Less vigorous arm swing better As a runner begins to fatigue the use of arm swing helps the runner to maintain lift and drive As a runner begins to fatigue the use of arm swing helps the runner to maintain lift and drive Elbows swing forward & backward in straight line Elbows swing forward & backward in straight line The angle of arm flexion should be around 90 degrees The angle of arm flexion should be around 90 degrees

10. swing support takeoff footstrike

11. First Principle Of Biomechanics Force must be applied to change the velocity of an object in motion Force must be applied to change the velocity of an object in motion Example: Example: A runner looses velocity during the airborne phase of each stride A runner looses velocity during the airborne phase of each stride To maintain continual motion- force usually applied by the support leg at takeoff ….. high impact forces in forefoot To maintain continual motion- force usually applied by the support leg at takeoff ….. high impact forces in forefoot Can gravity be engaged to maintain motion? Can gravity be engaged to maintain motion?

12. Second Principle Of Biomechanics Linear and angular motion need coordination/integration to permit optimum movement patterns Linear and angular motion need coordination/integration to permit optimum movement patterns Flexion and extension of the lower limbs work with the rotation, abduction, adduction of the hips and spine Flexion and extension of the lower limbs work with the rotation, abduction, adduction of the hips and spine All these movements about various planes must be complementary All these movements about various planes must be complementary

13. Third Principle Of Biomechanics The limbs are shortened to bring them forward with less energy requirement The limbs are shortened to bring them forward with less energy requirement Arm and leg recovery Arm and leg recovery Example…piano metronome Example…piano metronome

14. Fourth Principle Of Biomechanics For every action there is a reaction equal in amount but opposite in direction For every action there is a reaction equal in amount but opposite in direction 2 forces – Force of Gravity and the Road Coming at You 2 forces – Force of Gravity and the Road Coming at You Must work with these Must work with these

15. Lbs/inx2 Supinator Pronator

16. Dr. Tim Noakes 10 laws of running injuries South African physician, exercise physiologist, and ultramarathoner Can be applied to any sport which involves running, jumping, throwing, or any repetitive movement

17. 1. Running injuries are not an act of God 2. Each Running Injury Progresses Through Four Grades 3. Each Running Injury Indicates the Athlete Has Reached the Breakdown Point 4. Virtually all Running Injuries are Curable 5. X Rays and Other Sophisticated Investigations are Seldom Necessary to Diagnose Running Injuries

18. 6. Treat the Cause, Not the Effect 7. Rest is Seldom the Most Appropriate Treatment 8. Never Accept as a Final Opinion the Advice of a Nonrunner (may be biased view since Dr. Noakes is a runner, but there may be some truth to this) 9. Avoid the Knife 10. There is No Evidence that Running Causes Osteoarthritis in Runners Whose Knees Were Normal When They Started Running

19. Running Injuries….a necessary evil? Despite the fact that running seems safe compared to other athletic endeavors, it is a high injury sport Despite the fact that running seems safe compared to other athletic endeavors, it is a high injury sport Running injuries occur in between 29-90% of runners on an annual basis, depending on age and experience* Running injuries occur in between 29-90% of runners on an annual basis, depending on age and experience* * Sports injury bulletin 2007 Br J Sports Med 2003; 37:239-244 Br. J. Sports Med 2007; 41: 469 – 480 Sports Med 2007;37:437-9

20. Running Injuries-Current Treatment Traditional approaches have focused on: Traditional approaches have focused on: Treating local injury with rest, ice Treating local injury with rest, ice Anti-inflammatory medications (which indeed may inhibit healing) Anti-inflammatory medications (which indeed may inhibit healing) Orthotics and footwear- often with rigid support Orthotics and footwear- often with rigid support Stretching and strengthening exercises Stretching and strengthening exercises Modifying training and surfaces Modifying training and surfaces Despite all this “care” we have not had affect on actually reducing injury rates Despite all this “care” we have not had affect on actually reducing injury rates

21. Focus on Form? Michael Phelps with Bob Bowman Bowman legendary in Baltimore swimming circles for over 25 years as the stroke guru

22. Focus on Form? Tiger Woods and Butch Harmon Would we ever tell an entry level golfer to “just go hit more balls harder each day and it will all work out”

23. As doctors we are essentially advising “just go start running” …..but is there a better way?

24. The Gold Standard Perfect Posture Land with Bent Knees Under the Center of Mass Arms Relaxed At 90 degrees Slight Lean

25. The perfect form

26. Many feel like this when running

27. Look Ma…No Shoes Perfect form naturally

28. Ouch…no wonder half of runners get hurt each year and many quit for good

29. Let off the Brakes Keep the momentum in forward motion Keep the momentum in forward motion Land with your feet under your center of mass Land with your feet under your center of mass When you heel strike you take up the impact forces in your feet, lower extremities, pelvis, and back Then you must push off to accelerate

30. Background to our Survey Maybe we should give more “thought” and less “care” to these injuries Maybe we should give more “thought” and less “care” to these injuries No research has been performed looking at whether teaching proper running techniques can help one run more comfortably and injury free No research has been performed looking at whether teaching proper running techniques can help one run more comfortably and injury free The ChiRunning program, taught to thousands throughout the world, is by far the largest group who has tried a new technique The ChiRunning program, taught to thousands throughout the world, is by far the largest group who has tried a new technique Is it easy to learn? Is it easy to learn? Does it have any real impact on comfort and injury? Does it have any real impact on comfort and injury?

31. The Survey 25 question survey sent to approximately 25,000 through email. 25 question survey sent to approximately 25,000 through email. Readers of ChiRunning Book Readers of ChiRunning Book Participants in Workshops Participants in Workshops Visitors to the ChiRunning website Visitors to the ChiRunning website 2528 responses 2528 responses Approved through West Virginia University Institutional Review Board and using WVU Sole Survey Tool Approved through West Virginia University Institutional Review Board and using WVU Sole Survey Tool

32. The Survey Results The next 25 slides represent the responses to the questions. The next 25 slides represent the responses to the questions. There were also over 1500 comments in open comment sections which adds great insight into how people learn, how this program has affected people, and the challenges in learning. There were also over 1500 comments in open comment sections which adds great insight into how people learn, how this program has affected people, and the challenges in learning.

58. Key Findings Baseline injury rate > 50% in 6 months prior to ChiRunning (consistent w/current literature) Baseline injury rate > 50% in 6 months prior to ChiRunning (consistent w/current literature) Most injuries in knees, shins/calves, and feet/ankles (consistent w/current literature) Most injuries in knees, shins/calves, and feet/ankles (consistent w/current literature) Dramatically reduced rates of injury after learning the ChiRunning technique Dramatically reduced rates of injury after learning the ChiRunning technique Reduced levels of effort after learning technique Reduced levels of effort after learning technique Easy to learn and results felt quickly Easy to learn and results felt quickly Surgeries delayed for many Surgeries delayed for many

59. Limitations This survey went to a group who have done the program and may have felt in some way compelled to complete the online voluntary survey This survey went to a group who have done the program and may have felt in some way compelled to complete the online voluntary survey This may represent a higher proportion of positive results than would be seen in a prospective trial. Like many surveys the “believers” often take the time to complete them This may represent a higher proportion of positive results than would be seen in a prospective trial. Like many surveys the “believers” often take the time to complete them

60. The Technique Key concepts in ChiRunning: Principles from T'ai Chi introduced into running Alignment and Relaxation: Efficient body movement reduces dependency on muscle power. Positive Use of the Mind: The mind educates the body in efficient movement, instead of "mind over body.” Reduce Overuse Injuries: Focus on technique and mastery vs. results Reduce Overuse Injuries: Focus on technique and mastery vs. results

61. The Technique Specifics of the Technique Postural Alignment Postural Alignment Reduces wear and tear on the joints and muscles Improves performance Leaning Forward Leaning Forward Using gravity for propulsion Using gravity for propulsion reduces impact and overuse in the lower extremities

62. The Technique Relaxation in Movement Relaxation in Movement Creates a more fluid and efficient stride Lifting heels instead of pushing off Lifting heels instead of pushing off Reduces leg muscle usage Prevents overuse injuries of the lower leg

63. The Technique- Core and Posture Draw strength from your body's center, or core Draw strength from your body's center, or core spine and body's core muscles lift the legs, rather leg strength to push off. The legs follow, rather than lead. spine and body's core muscles lift the legs, rather leg strength to push off. The legs follow, rather than lead. Let gravity pull you forward Let gravity pull you forward Relax, bend your knees, and lean slightly forward at the ankles. As you lean, gravity pulls you forward. Relax, bend your knees, and lean slightly forward at the ankles. As you lean, gravity pulls you forward. Land with your feet underneath you, rather than in front of you Land with your feet underneath you, rather than in front of you Maintain excellent posture at all times Maintain excellent posture at all times Keep your hips, shoulders, and ankles in a straight line. Keep your hips, shoulders, and ankles in a straight line.

64. Chi Running Posture

65. Perfect Posture Feet aligned and hip width apart Ear, shoulder, hip, ankle all aligned You should be able to see your shoelaces Think of someone trying to pull you up by the back of your hair Soften knees Feel grounded

66. Main “Lifters” of Legs

67. Perfect Posture Think of your pelvis as a bucket Do not spill anything out

68. Anterior Pelvic Tilt Cannot activate Psoas Bend forward at waist a bit and lift your legs Engage core lower abs (cough) ….now lift your legs

69. One Legged Posture Stance Should be able to lift ankle with little to no upper body movement or hip shift

70. One Legged Posture Stance in Motion As you move forward and lean a bit- you are doing a series of one legged posture stances You are NOT pushing off Try it!

71. The Technique- Relaxing Relax your body and focus your mind Relax your body and focus your mind Tension restricts the flow of energy your body needs to run. Relaxing your leg muscles lessens their resistance to forward momentum as you run. Concentrating, especially on your posture and breathing, will help you maintain form. Tension restricts the flow of energy your body needs to run. Relaxing your leg muscles lessens their resistance to forward momentum as you run. Concentrating, especially on your posture and breathing, will help you maintain form. Breathe Breathe Inefficient breathing will make any exercise harder. Relaxing your mind and body will help you breathe more deeply and efficiently, powering your running. Inefficient breathing will make any exercise harder. Relaxing your mind and body will help you breathe more deeply and efficiently, powering your running.

74. Psoas stretch

75. Where to go form here? The number of responses and the extremely positive results of the ChiRunning intervention strongly suggests that our hypothesis may be true: The number of responses and the extremely positive results of the ChiRunning intervention strongly suggests that our hypothesis may be true: You can change your mechanics to a more efficient, lower impact form You can change your mechanics to a more efficient, lower impact form By doing this you can reduce injury and effort By doing this you can reduce injury and effort Running technique should and must be taught just as proper technique is taught in almost any sporting endeavor Running technique should and must be taught just as proper technique is taught in almost any sporting endeavor

76. Where to go form here? The best way to go forward is a prospective trial The best way to go forward is a prospective trial We will take similarly matched groups doing similar programs We will take similarly matched groups doing similar programs We will teach groups the technique in the same way a consumer would learn- some could be done by workshop, some with the book/DVD We will teach groups the technique in the same way a consumer would learn- some could be done by workshop, some with the book/DVD We will follow them forward compared to groups doing similar training programs without the technique intervention We will follow them forward compared to groups doing similar training programs without the technique intervention Ideal matched groups could come from marathon training programs and the military Ideal matched groups could come from marathon training programs and the military

77. Summary The number of responses and the extremely positive results of the ChiRunning intervention strongly suggests that our hypotheses may be true: The number of responses and the extremely positive results of the ChiRunning intervention strongly suggests that our hypotheses may be true: You can change your mechanics to a biomechanically more efficient, lower impact form You can change your mechanics to a biomechanically more efficient, lower impact form By doing this you can reduce your rates of injury and effort By doing this you can reduce your rates of injury and effort Running technique should and must be taught, just as proper technique is taught in almost any sporting endeavor Running technique should and must be taught, just as proper technique is taught in almost any sporting endeavor