a case report presented to the faculty of the department ... · a canon powershot elph 320 hs...

The Use of a Cost-Effective High Speed Video Camera to Assess Abnormal Gait

Mechanics in an Avid Runner with Lumbosacral Dysfunction.

________________________________________________________________________

A Case Report

Presented to

The Faculty of the Department of Rehabilitation Sciences

In Partial Fulfillment

of the Requirement for the Degree of

Transitional Doctorate of Physical Therapy

________________________________________________________________________

By

Patrick Davin MSPT, ATC, CSCS

2015

APPROVAL SHEET

This case report is submitted in partial fulfillment of

the requirements for the degree of

transitional Doctorate of Physical Therapy

_______________________

Patrick Davin

Approved: April 2015

____________________________

Eric Shamus PhD, DPT

____________________________

Arie van Dujin EdD, PT

The final copy of this case report has been examined by the signatories, and we find that both the content and the

form meet acceptable presentation standards of scholarly work in the above mentioned discipline

Acknowledgements

The author of this paper would like to acknowledge Dr. Eric Shamus PhD, DPT, CSCS and

Dr. Arie van Duijn EdD, PT, OCS for their significant contributions to this paper.

High-Speed Camera Gait Analysis 4

Table of Contents

Abstract 5

Introduction 6

Purpose 11

Case Description 12

Examination 14

Prognosis and Plan of Care 17

Intervention 17

Table 1: Summary of Goals and Interventions 18

Running Gait Analysis 20

Table 2: Summary of “Normal” Running Kinematics 24

Outcomes 24

Table 3: Results of Running Gait Analysis 25

Discussion 30

References 32


ABSTRACT

Introduction. The sport of long-distance running continues to grow exponentially, and

injury rates, associated with running remain high. Research has shown that abnormal

gait mechanics are a potential cause for injury. Traditionally, gait analysis studies of

injured runners have used expensive, highly technological equipment that is not readily

available or practical to use in most clinics. Purpose. This case report will demonstrate

the use of an inexpensive high-speed camera to analyze the gait pattern of an avid

runner presenting with lumbosacral dysfunction and referred symptoms into the left

lateral thigh. Case Description. The patient is a 46 y/o active female presenting with a

2-year history of left buttocks and thigh pain that after examination was felt to be due

to lumbosacral dysfunction. Running Gait Analysis. A Canon PowerShot ELPH 320 HS

camera and a Vision Fitness T9700 Series treadmill were used for videotaping and the

frame-by-frame analysis was performed using Kinovea. Outcomes. Through the use of

this camera, subtle gait deficits were able to be recognized and addressed accordingly

and our patient was able to return to running with minimal symptoms. In addition, this

paper will discuss how the use of the high-speed camera was successfully implemented

into the gait retraining component of our patient’s rehabilitation. By providing this

visual feedback during the gait retraining period, our patient was able to see how

effectively she was incorporating the recommended changes in her running pattern.

Discussion. This paper will also discuss the current research on impact peaks and various

strike patterns as well as the limitations of the two-dimensional motion analysis

systems.


INTRODUCTION

The sport of long-distance running has grown exponentially over the last few

decades. In 2013, all-time highs were seen in the number of male and female marathon

finishers (308,400, and 232,600 respectively). Over the last decade, there has been a

307% increase in the number of half-marathon finishers.¹ In addition, running is a low-

cost and convenient method of maintaining cardiovascular health and overall well-

being.

The popularity of long-distance running; however, does not come without a cost.

It is estimated that up to 79.3% of runners sustain lower extremity injuries at some

point during their training or competition.2 In addition, up to 92.4% of runners sustain

running-related injuries when injuries other than those isolated to the lower extremity

are included.2 This breaks down to 2.45 to 17.0 injuries per 1000 hours of running.³˒⁴

Compared to injury rates in other endurance sports including cross-country skiing

(males: 1.77, females: 2.33 per 1000 hrs), swimming (females: 1.94, females: 3.25 per

1000 hours), soccer (females: 3.25, males: 2.89 per 1000 hours) and triathlons (.92 per

1000 hours), injury rates associated with running are significantly higher.3 Most of these

injuries are lower extremity injuries with the most injury prone area being the knee (7.2

to 50%), followed by the lower leg (9 to 32%), and upper leg (3.4 to 38.1%).² Specific

injuries most often incurred by long-distance runners included patellofemoral

syndrome, Iliotibial band friction syndrome, tibial stress syndrome, plantar fasciitis,

Achilles tendonitis and meniscal injuries⁵ along with injuries to the sacrum and lumbar

spine.6 Furthermore, when runners try and increase their speed or distance, fatigue and


lack of flexibility and stability can be a contributing factor to altered running mechanics

and potential injury.

Recently, in the literature, significant attention has been given to gait mechanics

as a potential cause for injury.7 Daoud et al. found that the increased impact peaks

associated with rearfoot striking increases the rate of injury by two to four times. This

included injuries to the hip, knee, and lower back as well as tibial stress injuries, plantar

fasciitis, and stress fractures of the lower limb.7 It has also been suggested that forefoot

strikers may be more prone to injuries such as Achilles tendinitis or tendinosis, Achilles

ruptures and metatarsal stress fractures. It has been hypothesized that this may be due

to the altered gait mechanics and increased use of the gastrocs/soleus complex during

forefoot running; though, initial studies on this have been inconclusive. 7, 8 In addition,

alterations in gait pattern have also been noted in runners returning from injury. It has

been suggested that these changes seen in running mechanics may be compensatory

due to pain adaptations or due to changes in neuromuscular strategy secondary to

weakness, instability or tightness of soft tissue structures.9

Despite this recent focus on gait analysis and running injuries, research on a

practical, cost-effective means in which to perform clinical gait assessment remains

limited. Most of the research studies have used expensive gait analysis systems with

multiple cameras, reflective markers, force plates and 3D motion analysis systems.7-12

Without a doubt, these highly technical systems provide invaluable information in

regards to the kinematics of running and ground reaction forces sustained by the


runners. In addition, these systems will easily pick up on any of the biomechanical flaws

that may be present in the injured runner.

In the research focusing specifically on the use of these sophisticated motion

analysis systems, studies have demonstrated moderate to good reliability with

coefficient of multiple correlations ranging from 0.70 to 0.93.13-16 Coefficients of

multiple correlations were found to be over 0.70 in a study by Queen et al 13 when

ground reaction forces along with angular velocities were measured for the knee and

ankle at both self-selected and standardized running speeds. Pohl et al 14 demonstrated

good reliability (≥ 0.803) when assessing lower extremity kinematics and various marker

placements. A systematic review by McGinley et al 16 found that in the analysis of both

running and walking gait using various motion analysis systems, there was variation in

the reliability measures dependent on the plane being assessed. Reliability in the

sagittal plane was found to be highest at > 0.8 in most studies, followed by > 0.7 in the

coronal plane with the lowest rates of reliability occurring in the transverse plane at < 0

.7. It has also been noted that using the means of additional trials for gait analysis can

increase reliability rates to > 0.93 (5 trials) though an 80% confidence level can be

achieved with means from 3 separate trials.17

The main limitations with these types of systems are that they are neither

practical nor affordable for most clinics, and they tend to be used more frequently in

research-based settings. In addition, during real-time analysis of running gait with the

naked eye, most clinicians will only be able to visualize the more obvious gait


abnormalities, and many of the more subtle gait deviations will be missed without

performing a slow-motion, frame-by-frame analysis.

Recently, more cost-effective two-dimensional cameras have been used in the

clinical setting for walking and running gait analysis though reliability and validity

measures specific to running are limited. Less-sophisticated, two-dimensional systems

have been used clinically to research strike pattern in runners 18 A two-dimensional

system demonstrated good concurrent validity when compared to the three-

dimensional Vicon motion analysis system during analysis of kinematic and temporo-

spatial variables in walkers.19 Strong correlations were noted (R2 = 0.999) between the

two-dimensional and three-dimensional systems. High intra-rater and inter-rater

reliability were also noted between these systems with this particular study showing an

intra-rater reliability of 0.993 for the kinematic variables measured, and a range from

0.941 to 0.956 for the temporo-spatial variables. For inter-rater reliability, ICC values

were found to be ≥ 0.822 for all variables. 19

Brunnekreef et al.20 used a similar system in their analysis of abnormal walking

gait of participants with various orthopedic issues. In this study, it was found that

Intraclass Correlation Coefficients (ICC) for inter-rater reliability ranged from 0.40 in the

lesser-experienced clinicians to 0.54 in those clinicians with the most experience. Intra-

rater reliability for gait analysis ranged from 0.57 to 0.74.20 The use of a 2-dimensional

video system also showed moderate reliability when compared with a more complex 3D

system to screen for excessive valgus during a functional movement screen, correlating

well with 2 of the 3 functional movements (r2 ranging from 0.58 to 0.64).21 With studies


showing moderate reliability of measurements with the low-cost 2D system, it was felt

that this justified its use on our patient.

Low cost gait analysis options are available. A Canon PowerShot ELPH 320 HS

camera which shoots videos at 30 frames per second is not expensive and can be

utilized in the clinic. This frame rate has been shown to be adequate for analysis in prior

studies.22 Many other low cost cameras (< $300) that record video at 30 to 60 frames

per second are available. Though not an all-encompassing list, these include the Canon

Rebel T5i ($200; 1080p at 30fps), the Nikon Coolpix L830 ($197; 1080p at 30fps), the

Panasonic Lumix DMC-LF1 ($290; 1080p at 60fps); the Kodak PixPro AZ 521 ($220; 1080

at 30fps), the Canon PowerShot SX600 HS ($199; 1920X1280 at 30fps), and the Fujifilm

FinePix series ($194-260; 1080p at 60fps). Many other cameras appropriate for

recording running gait analysis are also available; though a more in-depth analysis of

camera options and features is beyond the scope of this paper.

There are other options with smart phones, tablets or iPads, which also typically

shoot video between 30 and 60 frames per second, adequate for slow-motion frame-by-

frame analysis. One of these is an application through Ubersense

(www.ubersense.com). Once installed, videos can be recorded and analyzed

accordingly. Features of this program include real-time and slow-motion playback,

frame-by-frame analysis through scrolling option, kinematic analysis through use of

angular measurement tools, drawing tools and use of a timer. The most basic

Ubersense option is free though some of these additional features can be purchased for

$20 through the Ubersense website or smartphone app store. This program also allows

http://www.ubersense.com/


for simultaneous comparison of videos in real-time, slow-motion and frame-by-frame

playback modes. Videos can also be shared via email with patients and/or clients.

Another program that can be used with iPads and iPhones is through Dartfish

(www.dartfish.com). Similar to the Ubersense program, videos can be recorded using

the phone or tablet’s built-in camera. These can then be played back in slow-motion or

via frame-by-frame analysis. Additional features of this program include the ability to

add in drawings, labels, angles as well as text or voice notes. This program is available

through the itunes store for $6.99. These advances in new technology are leading to

the ease of use for physical therapist in every day clinical practice.

PURPOSE

The purpose of this case report was to describe the use of a cost-effective high

speed camera to analyze abnormal gait mechanics in an avid runner presenting to the

clinic with lumbosacral dysfunction and referred pain into left lateral thigh. This case

report will demonstrate how frame by frame slow-motion analysis using this relatively

inexpensive tool provided valuable insight into gait deviations during the initial

examination that may not have been picked up on via real-time analysis. Currently, in

the literature, gait analysis studies have used expensive, highly technological equipment

that is not readily available or practical to use in most clinics. This case report will focus

on the practical use of this relatively inexpensive high-speed camera to analyze the gait

pattern of an avid runner presenting with lumbosacral dysfunction and referred

symptoms into the left lateral thigh.

http://www.dartfish.com/


CASE DESCRIPTION

The patient was a 46 year-old active female presenting to physical therapy with a

2-year history of left buttocks and thigh pain that began while training for an Ironman

event. Initial diagnosis from the physician was for left Iliotibial band (ITB) syndrome.

The patient had been very active prior to her onset of symptoms having been an avid

runner and triathlete. Over a 13-year period, she reported having completed 7

marathons and 2 Ironman events. In addition, she worked fulltime as an attorney and

was the mother of 2 children, ages 13 and 15. Patient’s past medical history was

significant for rheumatoid arthritis (RA) which she was diagnosed with 5-years ago. She

reports her RA symptoms being currently controlled with Enbrel.

Her chief complaint upon presenting to the physical therapy clinic was her left

lateral thigh and buttocks symptoms that she had intermittently over the last 2 years.

She described this as a burning pain into her left buttocks and lateral left thigh (per

patient, ranging from 2-8/10 on a numerical rating scale) that radiated inferiorly to just

distal to the lateral joint line of her knee. She stated that this burning sensation

increased after several minutes of sitting and when driving in the car. Functionally, in

addition to the increased symptoms with sitting and driving, the patient reported having

stopped running completely over the last 1 ½ years secondary to left buttocks and

lateral thigh pain immediately upon initiation of running.

Diagnostic testing for this patient included frontal and frog-lateral radiographs

on her left hip soon after the initial onset of left buttocks and lateral thigh symptoms.

Findings of these radiographs were mostly unremarkable per the radiologist report and


included preserved alignment and cartilage spaces of the hip, an intact left sacroiliac

joint, and no abnormality of overlying soft tissues. Tiny calcifications were found on the

left ischial tuberosity which the radiologist suspected to be due to chronic

enthesopathy.

The patient reports having been referred for formal physical therapy with a

diagnosis of Iliotibial Band Syndrome (ITB). Patient also had cortisone injections into her

left hip without appreciable changes in symptoms. In addition, the patient states that

she had continued to work out with a personal trainer at her local gym for her

suspected ITB syndrome at the time of her evaluation. However, she had reported no

significant, long-term relief of symptoms following sessions with her personal trainer.

Treatment focus during these sessions with her personal trainer had included stretching

and massage to the left ITB band, and self-myofascial techniques using a foam roller.

Unfortunately, despite her prior physical therapy and current training at the gym, no

resolution of symptoms had been noted.

Based on the location and type of pain, a lower quarter and neurological screen

was performed. The lower quarter screen revealed weakness of the patient’s left hip

abductors (4-/5), hip extensors (4-/5) and hip external rotators (4-/5) during manual

muscle tests.23 Active and passive range of motion of the hips including internal and

external rotation was normal and pain-free. Postural assessment showed a posterior

rotation of the left innominate in standing. This was confirmed by performing the long

sit test.24 An Ober’s test for ITB tightness and a Thomas test were both performed to

assess muscle length; both of which were found to be negative. The neurological screen


revealed normal L4 and S1 reflexes, normal sensory testing and 5/5 strength with

assessment of L2 to S1 myotomes. The only significant weakness of the lower

extremities was found to be with resisted hip abduction, extension and external rotation

of her left leg. Though these motions are at least partially innervated by the L5

myotome, hallux extension and resisted inversion and eversion of the ankle (all having

L5 components) were found to be 5/5. Therefore, it was hypothesized that the

weakness found with resisted hip abduction, extension and external rotation was due to

a weakness of this patient’s gluteal musculature as opposed to being a true myotomal

weakness.

The clinical decision-making process used to select the following tests and

measures for the patient was based on the fact that the patient had increased

symptoms when sitting and driving and ITB muscle length was normal with testing. At

this time, it was felt that the patient’s symptoms did not match her diagnosis of ITB

syndrome. Therefore, the focus of the assessment shifted towards the sacroiliac joint,

the lumbar spine and the piriformis muscle. At this time, it was also felt that the patient

would be a good candidate for video analysis of her running gait based on the fact that

her symptoms began while running and that she continued to experience this left

buttocks and lateral thigh symptoms within 2 to 3 minutes of any attempts at running.

The video analysis will be utilized to identify abnormal biomechanics.

Examination

Active range of motion (AROM) testing of the lumbar spine was assessed.25 This

was found to be mildly to moderately impaired in the sagittal plane with both lumbar


spine flexion and extension with the patient demonstrating 58 degrees of L/S flexion

and 14 degrees of extension. The patient also demonstrated 28 degrees of left

sidebending and 24 degrees to right. Lumbar spine rotation was found to be normal

bilaterally. Repeated movements were performed to assess centralization and/or

peripheralization of symptoms. It was noted that lateral thigh symptoms increased with

repeated flexion and there was a tendency for centralization of symptoms with

repeated extension. Slump testing24 did also reproduce some of the patient’s lateral

thigh symptoms. The examination then shifted to the sacroiliac joint and a cluster of

tests was performed. Prior studies have demonstrated increased sensitivity, specificity,

and predictive values when several tests are used in the assessment of sacroiliac joint

dysfunction (SIJD).26, 27 The Anterior Sacroiliac Joint Stress Test and Posterior Sacroiliac

Joint Stress Tests24 were found to reproduce pain in the left sacroiliac joint region. A

positive thigh thrust test was also noted on the left. Left-sided SIJ pain was also noted

while performing a FABER or Patrick’s test.25 Left-sided SIJ pain was noted at 83

degrees with SLR testing.24 A range between 70 to 90 degrees has been hypothesized to

be related to SIJD.24

Based on the examination data, it was felt that the patient had lumbosacral

dysfunction. Clinical reasoning for this included the fact that patient had

peripheralization of symptoms with repeated lumbar spine flexion and a tendency

towards centralization with repeated extension of the lumbar spine. Neural tension and

reproduction of symptoms were also noted with Slump testing of her left lower

extremity. However, SIJD could not be ruled out entirely due to the patient having 4


positive pain provocation tests specific to the SI joint. Research has shown that 3 or

more positive pain provocation tests results in 0.850 sensitivity and 0.764 specificity for

SIJD.26 A diagnostic odds ratio of 17.162 was also correlated with 3 or more positive pain

provocation tests for the SIJ.26 Studies have also demonstrated that patients with known

SIJD can have pain into buttocks (94%) as well as into thigh (48% overall; 20% have pain

specifically in lateral thigh) 28; both of which our patient had. Based on these findings,

the patient presented with a classification of lumbar dysfunction and also demonstrated

SIJD based on the cluster of tests performed. ITB syndrome was ruled out secondary to

the patient’s symptoms not correlating with this diagnosis including increased pain with

sitting and driving along with a negative Ober’s test.

The patient did demonstrate tightness of her left hip flexors with modified

Thomas testing.24 In addition, with the patient’s weakness of the left hip abductors,

external rotators and extensors, it was hypothesized that these muscle imbalances

could have contributed to the lumbar spine and SIJD that was present while running. It

was felt that slow-motion, frame-by-frame assessment via video analysis of this

patient’s running gait would be advantageous in evaluating any altered mechanics that

may have contributed to the patient’s pathology. This then could be addressed more

thoroughly through proper gait retraining once the patient was able to return to

running.

Prognosis and Plan of Care

This specific patient’s main goal was to resume running. In conjunction with the

patient, it was decided that our goal would be for her to eventually be able to run a 5K


road race symptom-free. Based on the fact that she had been unable to run at all over

the last 2 years, it was felt that this would be a good starting point for her with a

potential long-term goal of resuming her training for marathons and triathlons of which

she had previously participated in. In addition, it was also felt that increasing the

patient’s sitting tolerance to greater than 1 hour without radicular symptoms would be

important due to her job requiring periodic commuting and sitting for long periods of

time with clients.

Overall prognosis was thought to be good for centralizing patient’s left thigh and

buttocks’ symptoms, restoring overall muscle balance and pelvic symmetry, decreasing

pain and returning the patient to running at a modified level. This is due to the fact that

although the patient had been receiving various treatments over the last 2 years for

these symptoms without resolution, none had focused on the lumbar spine or SIJD. By

addressing the lumbosacral and SIJD through the interventions already discussed, it was

felt that patient would have minimal to no left buttocks pain with prolonged sitting and

that she would be able to run 3 to 5 miles 3 to 5 times per week without difficulty.

Intervention

The initial focus of our sessions would be to attempt to centralize patient’s

radicular symptoms, restore normal symmetry of the SIJ as well as addressing the

patient’s noted muscle imbalances through muscle energy techniques and mobilizations

of the pelvis, as well as strengthening of the core, hip abductor, extensor and external

rotators (Table 1). Though there are discrepancies in the literature regarding ideal

treatment of lumbar spine and SIJD, it has been shown that a program consisting of


lumbopelvic stabilization, core strengthening and joint mobilizations have been effective

in reducing symptoms of both.29-31 It was felt by this clinician that establishing pelvic

symmetry and correcting any muscle imbalances were necessary prior to initiating any

running program due to the exceedingly high stresses placed on the body during this

activity. During this period, the patient would be seen in the clinic 2 times per week for

4 to 6 weeks.

Once this pelvic symmetry and muscle balance were attained, then gait

retraining focusing on any abnormal gait mechanics during running picked up by the

slow-motion analysis would be addressed. The use of verbal and visual feedback using a

mirror and videotaping would be incorporated into treatment as well. Initial feedback

would be higher with a gradual reduction in this over time. During the gait retraining

period, the patient would continue to be seen 2 times per week initially, and as

feedback was reduced, the frequency of the visits would be reduced to 1 time per week.

Table 1: Summary of Goals and Interventions

Period Goals Interventions

Initial 3 Weeks Centralize left Buttocks and thigh symptoms Restore normal SIJ symmetry

POE, prone press-ups; Grade III PA mobilizations of L/S MET to correct posterior rotation of left innominate. Sacral mobilizations focusing on anterior left innominate in prone as described by Dutton.24


Table 1 (continued)

Period

Goals

Interventions

Correct muscle imbalances

S/L left hip ABD strengthening; hip ER strengthening via clam shells with theraband; resisted side-stepping with theraband; single-leg bridge on left; closed chain left gluteus medius strengthening including steamboats

Weeks 3-6 Maintain normal SIJ symmetry by continuing to address weaknesses of: Core Left hip ABD/ER/EXT

Transverse Abdominus holds with marching, heel slides, single-limb lowering, double-limb lowering, bicycle kicks; prone planks, prone planks with hip EXT, side planks, side planks with hip ABD; alternating hip EXT in quadruped Resisted side-stepping with theraband; single-leg stability exercises on Bosu ball; closed-chain left hip ABD/EXT strengthening including steamboats, pushing right LE into wall in SLS on left


Table 1 (continued)

Period

Goals

Interventions

Weeks 6+

Transition to HEP

Gait Retraining

Patient to continue with high-level core and left hip strengthening exercises at home as focus shifts to running gait retraining. Video analysis of running gait performed (see text for more details). Emphasis during gait retraining was on transitioning to forefoot strike pattern, decreasing step length B/L, decreasing pelvic drop and increasing cadence.

Abbreviations: POE, prone on elbows; SIJ, sacroiliac joint; MET, muscle energy technique; S/L, sidelying; ABD, abduction; ER, external rotation; EXT, extension; LE, lower extremity; SLS, single-leg stance; B/L, bilateral

RUNNING GAIT ANALYSIS

Approximately 6 weeks into formal physical therapy, the patient was

demonstrating improved symmetry of the pelvis as evidenced by postural assessment in

standing and supine as well as negative findings on the long-sit test as described by

Dutton.24 Also at this time, the patient was demonstrating 5-/5 strength with manual

muscle testing of hip extension, abduction and external rotation performed as described

by Kendall. 23 The patient was also reporting a significant decrease in lateral left thigh

symptoms (0/10 on a numerical rating scale) and symptoms into left buttocks (2/10 at

worse on a numerical rating scale only after prolonged sitting and driving > 60 minutes).


Improved stability and proper alignment were also noted in left lower extremity during

motor learning activities to improve proprioception and kinesthetic sense in the closed

chain in preparation for running. Activities included resisted side-stepping with squats,

diagononal lunges (resisted), standing “Ts” for stability and proper alignment and single-

leg stance on Bosu with opposite hip abduction.

At this time, it was felt that the patient would be appropriate for running gait

analysis with the high-speed camera. A Canon PowerShot ELPH 320 HS camera which

shoots videos at 30 frames per second was used for running gait analysis. Gait analysis

was performed on a Vision Fitness T9700 Series treadmill. The treadmill was used for

ease of use and practicality purposes during videotaping. Research has shown a 0.94

symmetry and similar kinetic and kinematic trajectories between treadmill and

overground running when comparing hip, knee and rearfoot 3D kinematics. 11, 32

Immediately following the videotaping, the data would be uploaded to the

computer program, Kinovea, for analysis. This is a free video player and editor program

that was downloaded from www.kinovea.org. Some of the features of this program

include variable playback speed and slow-motion frame-by-frame analysis, comparative

and synchronized analysis of 2 videos using multiple playback screens simultaneously, a

magnifying option and measuring functions including time and distance measurements,

as well as the ability to track and measure body parts and joints.

The patient, after a brief warm-up consisting of a light jog at 4.0 mph for 2

minutes was instructed to increase the speed of the treadmill to her “comfortable

running pace.” This is based on prior research demonstrating that repeatability of the


research variables was not altered significantly when comparing self-selected and

standardized running speeds.13 The patient ran at the self-selected speed of 5.5 mph at

a level grade.

Videotaping was performed both anteriorly and posteriorly to assess frontal

movements as well as from both the right and left sides of the patient to assess the

sagittal plane movement. The recording clinician maintained an approximate distance

of 2 meters at all times while recording, which has been deemed an appropriate

distance in prior studies for accurate analysis.21 Approximately, 30 to 45 seconds of

video were recorded from each position making sure to acquire whole body views with

the camera completely zoomed out initially; followed by assessment of specific areas of

the body with the camera zoomed in to the trunk, hip, knee and foot and ankle. Careful

consideration was given to make sure that each body segment and articulation was

recorded with the camera lined directly horizontal to it to prevent image distortion.

Videotaping was initially performed with shods (shoes) donned and was

repeated with the patient barefoot to assess variations in footstrike pattern. For each

condition, the patient ran for 3 minutes. Pain rating was assessed using a numerical

rating scale for each minute the patient continued to run on the treadmill. Following

the video recording, the patient was allowed to cool down as needed.

Frame-by-frame analysis was performed using the Kinovea program previously

discussed. Initial assessment focused on the series of videos with shods to get a sense

of the patient’s more “natural” gait pattern. Approximately 10 to 15 stride sequences

were analyzed with the clinician first looking at the entire body alignment and then


focusing in on the trunk, pelvis, hip, knee, ankle and foot. This was repeated for both

sagittal plane views and anteriorly and posteriorly for the frontal plane assessments. In

the sagittal plane, the degree of trunk flexion and extension was noted as well as the

degree of anterior or posterior pelvic tilt. Also in the sagittal plane, the degree of hip

and knee flexion and extension was noted at initial contact and during peak stance. The

degree of ankle dorsiflexion and plantarflexion was noted at initial contact as well as

peak stance. In the frontal plane, the degree of contralateral pelvic drop was assessed

as well as hip adduction and knee valgus/varus angles. Rearfoot eversion angles were

also assessed from the posterior view. These kinematic variables had been selected in

prior research studies during their analysis of gait mechanics using more sophisticated

motion-analysis systems. 8,10,33

This same series was then repeated for the barefoot running videos, paying

particular attention to any changes noted in foot strike, stride length, knee flexion and

dorsiflexion angles with shoes off as studies have demonstrated significant changes in

these variables when running barefoot.10 In addition to comparing running gait

kinematics during both shod and barefoot running, an analysis of the two for any

changes in the patient’s symptoms would also be performed. The patient had never

attempted running barefoot or with minimalist footwear prior to this running gait

analysis. Through this comparison of gait kinematics of the two conditions and while

monitoring the patient’s overall symptoms, it was felt that essential information could

be gathered in regards to potential gait alterations that could be suggested during the


gait retraining period. Any gait abnormalities were noted and recorded accordingly

during analyses of the two running conditions.

What constitutes normal running gait is a source of debate in the literature.

Table 2 summarizes the variations of “normal” running kinematics for the trunk, pelvis,

hip, knee, foot and ankle that researchers have found in their respective studies.

Though what constitutes “normal” gait is somewhat inconclusive, this criteria was used

to compare our patient’s running gait to the established norms.

Table 2: Summary of “Normal” Running Kinematics Found in Literature8, 10, 34, 35

Variables Normal Running Barefoot Running

Trunk Flexion 2.4 to 13° N/A

Pelvic tilting 15-20° of ant tilt N/A

Contralateral Pelvic Drop -3.9 to -6.6° N/A

Hip ADD 11.9 to 17.8° N/A

Hip angle at IC 26.04° 20.76°

Knee angle at IC 12.73° 13.63°

Peak stance knee flex 50.97° 48.57°

Ankle angle at IC 5.31 to 14.85° 0.03° to 0.78°

Peak stance ankle DF 27.51° 24.94°

Rearfoot Eversion -.9.4° N/A

Abbreviations: ant, anterior; ADD, adduction; IC, initial contact; DF, dorsiflexion


OUTCOMES

Table 3 summarizes the results of our patient’s running gait analysis. Compared

to the existing normative data, the degree of pelvic tilt, contralateral pelvic drop, hip

adduction, hip flexion at initial contact, and ankle dorsiflexion at initial contact (with

shoes on only) all fell within comparable ranges. Data that fell outside the normal

ranges included the degree of trunk flexion (this patient actually demonstrated 5

degrees of trunk extension with both shod and barefoot running), knee angle at initial

contact (18 and 16 degrees respectively, with shods on and off compared to 12.73 and

13.63 with normative data), peak stance knee flexion (40 and 46 degrees respectively,

with shods on and off compared to 50.97 and 48.57), ankle angle at initial contact

during barefoot running (-3 degrees in our patient, compared to .03 to .78), peak ankle

dorsiflexion during stance (17 and 10 degrees in our patient compared to 27.51 and

24.94), and rearfoot eversion, which fell slightly out of normative range at 12 degrees

for both shod and barefoot running when compared to 9.4 degrees.

Table 3: Results of Running Gait Analysis

Variables Normal Running Barefoot Running

Trunk Flexion -5° (EXT) -5° (EXT)

Pelvic tilting 17° of ant tilt 17° of ant tilt

Contralateral Pelvic Drop 4° L stance

7° R stance

4° L stance

6° R stance

Hip ADD 15° 16°

Hip angle at IC 26° 23°


Table 3 (continued) Variables

Normal Running

Barefoot Running

Knee angle at IC

18°

16°

Peak stance knee flex

40° 46°

Ankle angle at IC 6° -3° Peak stance ankle DF 17° 10°

Rearfoot Eversion 12° 12°

Abbreviations: EXT, extension; ant, anterior; L, left; R, right; ADD, adduction; IC, initial contact; DF, dorsiflexion

The patient demonstrated 5° of trunk extension during both shod and barefoot

running, compared to prior studies of “normal” running gait demonstrating norms

between 2.4 to 13° of trunk flexion. This placed the lumbar spine in more extension.

The patient did have some centralization of symptoms with prone on elbows, prone

press-ups and repeated extension of her lumbar spine during her initial treatment

sessions. Therefore, it was hypothesized that this may have been compensatory to

avoid more relative lumbar flexion and associated symptoms while running.

In addition, there was a significant change in the patient’s left buttocks

symptoms when comparing the 2 running conditions. The patient reported up to 4/10

left buttocks pain on a numerical rating scale during shod running with rearfoot strike.

This pain had steadily increased for each minute that the patient was running with shoes

donned up to the 3-minute mark in which the treadmill was then stopped to allow the

patient to remove her shoes for barefoot analysis. When the patient was performing


the barefoot video analysis, her reported left buttocks symptoms on the numerical

rating scale never exceeded 1/10.

Interestingly, when comparing strike pattern, there were no apparent

differences between conditions as our patient appeared to demonstrate a strong

rearfoot strike with both. Differences in stride length were noted when performing the

comparative and synchronized frame by frame analysis of the 2 videos/conditions. This

was confirmed by computing gait cadence as it was deduced that an increased number

of steps in the same length of time (if running at the same treadmill speed), would result

in a decreased stride length. Gait cadence for the shod condition was 156 steps per

minute compared to 160 steps for the barefoot condition.

As a result of the findings, the emphasis during the running gait retraining

program was to shift towards more of a forefoot strike pattern while also attempting to

decrease the stride length bilaterally. This was based on the fact that there was a

definitive trend towards a reduction in patient’s left buttocks symptoms during the

barefoot running condition with a decreased stride length, even though no obvious

differences in strike pattern were noted visually during the frame by frame analysis. The

patient was allowed to run with shods donned as she easily transitioned to a forefoot

strike pattern with only minimal verbal cueing to do so (see Figure 1).


Figure 1: Comparison of Strike Pattern Before and After Gait Retraining A. B.

Over the course of the next 4 sessions, the treatment focus continued to be on

gait retraining on the treadmill based on our video analysis. Verbal feedback as well as

visual feedback through the use of the camera and frame-by-frame analysis was initially

provided to assist the patient in attaining the desired forefoot strike pattern and

increased gait cadence. Both verbal and visual feedback were reduced over time. Gait

retraining continued to be performed at a self-selected running speed as long as the

patient was able to maintain proper running form. This was 5.5 mph initially which was

increased to 6.0 mph over the course of these sessions. The patient ran up to 1 mile for

the initial 3 sessions and progressed to 1.15 miles for the following session.

Gait cadence was also monitored secondary to attempting to decrease overall

stride length. With verbal cueing to “land on toes” and to “soften landing,” it was noted

that the patient increased her cadence by over 10% when comparing her original

cadence of 156 steps per minute (rearfoot strike pattern with shoes) to her current 172

steps per minute (forefoot strike pattern with shoes donned).

B, Depicts forefoot strike pattern demonstrated after gait retraining

A, Depicts rearfoot strike pattern seen during initial gait analysis.


Pain was also continuously monitored on the numerical rating scale during

running gait retraining activities. This continued to fall in the range of 0-1/10 for left

buttocks symptoms for running emphasizing forefoot strike and decreased stride length.

Interestingly, when the patient was cued to return to her “natural” running form

(rearfoot strike), the symptoms progressively returned in her left buttocks. Therefore,

continued emphasis was on transitioning to a forefoot strike pattern and increasing gait

cadence.

At the time of this writing, the patient was continuing to work on gait retraining

both in the clinic and at home. She was being transitioned out of formal physical

therapy and initiating a home running program. The patient was instructed to increase

her distance by no more than 10% each week and to limit this increase or even decrease

mileage if any symptoms returned.

Overall, it was felt that incorporating this simple, yet effective clinical

measurement tool into the assessment of an injured runner provided both the clinician

and patient with valuable data in a practical and efficient manner which assisted in the

development of effective treatment strategies. The patient feedback was also very

positive in that she found it helpful to be able to go through the frame by frame video

analysis with her therapist to see exactly where her deficits were. The patient felt the

ability to see on the images gave her great feedback on what her mechanics were and

how to change the mechanics. The patient said she could not visualize what was being

referred to when discussing her running mechanics. Though there may be a bit of a

learning process associated with using the camera and the Kinovea motion analysis


program with a clinician who is unfamiliar with these, both tools are relatively easy to

use, especially with continued practice and experience.

The video analysis also demonstrated its usefulness as an intervention tool in its

ability to provide intermittent visual feedback through video recording and frame by

frame analysis during the gait retraining period. This allowed the patient to see how

successful she was in implementing the recommended changes into her running gait. By

using the side-by-side synchronized comparison, the patient was able to simultaneously

watch videos of what her initial running gait had been compared to her current form.

DISCUSSION

The purpose of this case report was to show how recent advances in technology

at a low or free cost can be incorporated into the running gait assessment of an injured

runner. Through the use of this cost-effective, two-dimensional motion analysis system,

it was determined that in this patient, there were some abnormal gait mechanics which

may have been a factor in her increased buttocks symptoms with running. By

addressing her strike pattern, stride length, and gait cadence, our patient was able to

return to running virtually pain-free. Prior research has demonstrated similar results.

Research has shown that vertical impact peaks are significantly reduced by adopting

more of a forefoot strike as evidenced by research on barefoot running.34, 35 Prior

research has proposed that increased injury rates in shod rearfoot strikers may be due

to higher impact peaks and ground reaction forces sustained during this strike pattern

when compared to barefoot running and the adopting of more of a forefoot strike

pattern.7,36


The use of a two-dimensional high speed camera is certainly not without its

limitations. Compared to other three-dimensional, more sophisticated motion analysis

systems, the use of a simple two-dimensional system will not provide the kinetic data

that researchers were able to attain using force plates in other studies.8,10 Therefore,

data in regards to ground reaction forces, impact peaks, work done and power

generated at individual joints will be limited. However, in regards to kinematics, this

case report demonstrates how the use of a more cost-effective high speed camera can

produce results similar to that of the more expensive motion analysis systems. This was

particularly true when assessing the movements of the trunk, pelvis, hip, knee, ankle

and foot in the frontal and sagittal planes from anterior, posterior and lateral views.

Though an appreciation for transverse plane movement could also be appreciated at

these various segments as well through the use of our camera and motion analysis

system, its inability to quantify these motions as a sophisticated system using reflective

markers is able, was a limitation of this type of system.

Findings from this case report do support the need for further studies on the

reliability of the high-speed camera as an assessment tool. If shown to be reliable and

valid, this assessment tool could be invaluable in the clinical setting for its use in

assessing the biomechanics of the injured runner. Clinicians would be able to assess

running gait mechanics in an every day clinical practice in an efficient and cost-effective

manner; potentially, leading to improved intervention strategies and overall patient

outcomes.


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