Friday, October 24, 2014

My Evening at UCSF's RunSafe Clinic

If you live in the Bay Area or in Boston, you may be familiar with the RunSafe program.

From the website:

RunSafe is a sports wellness program for runners that focuses on personalized health advice, injury prevention, and performance enhancement. The development of the program started in 2006, when sports medicine professionals at the University of California, San Francisco felt there was a need to provide a service to runners that focused on injury prevention to improve performance rather than treating injuries alone....Using a scientific approach, our experts' comprehensive, ongoing review of the sports medicine research helps build the foundation for the program.

Mission of RunSafe:

To improve health of individual runners and advance the science and medicine of running.

These include:

    1. Delivering advice on the best practices for training and health for runners of all levels.
    2. Educating runners in areas of injury prevention.
    3. Developing the RunSafe program as an evidence based standard in running assessment.
    4. Creating a database to further scientific study to learn about runner practices and issues.

The appointment is two hours long, wherein you get videotaped on a treadmill for ~10 minutes (after a warm-up period), go through a battery of strength & flexibility assessments, get evaluated by a foot-and-ankle specialist both barefoot & in all your different shoes, & consult with a sports dietition re: your diet/nutrition stuff. There are four runners who rotate through each of the four stations, and then at the end you watch all your videos together & the panel presents each you with an overall assessment & personalized recommendations in the different areas.

I have been meaning to do this for literally years. When I first found out about it I was working part-time as a consultant, paying my health insurance out of pocket, & trying to climb out of credit card debt, so as fantastic as it sounded, the $200 fee was more than I could justify. I told my mom about it and she offered to pay for it as a combined Christmas/birthday present, and I am not even kidding that a month later they raised the fee to $400.

Over the next couple of years my financial situation improved, but I still felt like $400 was a bit steep, even if I wasn't paying for all of it myself. This last year, though, they lowered the price to $300, but since I was in PT at The Human Performance Center with their main running guy anyway, it seemed like kind of a waste. (Also when you're trying to rehab an injury that put you on crutches did not seem like the best time to have people commenting on your form.)

On the other hand, my PT thought I might find it helpful to do at some point when I was healthy. So I got myself healthy again, and about halfway through my Santa Rosa training I went ahead and snagged myself a spot at the end of September, figuring that would give me enough time to recovery from whatever Santa Rosa brought my way. (Alas, it got rescheduled to Oct. 6 due to a glitch with the system, but what can you do. On a related note, if it is the day of your appointment and you have not gotten any emails from the RunSafe people besides a receipt, you probably should have double checked with them sooner. Oops.)

The clinic started with introductions, which included a PT professor & two of his grad students (who did the gait analysis), a clinical PT (who did the strength/alignment/flexibility testing), my sports medicine doctor (who did the foot/ankle/shoe analysis bit), and a sports dietition (who SURPRISE! did the diet/nutrition part).

Disclaimer: I did not want to be the douche snapping pictures of everything while people were trying to do their jobs, so instead I have google'd RunSafe & used a bunch of pictures off the internet to give you a sense of what it's like. Hope that helps. Sorry for not #keepingitreal. Bad blogger. But on the other hand, maybe less irritating to those around me.

My first stop was with the PT. I gave her my injury history & told her about my hip alignment problems, which she easily confirmed; other than that, she said my alignment looked good. With the number of hours (hundreds? thousands?) I have spent on PT tables or doing PT exercises or getting strength tested by PTs, I would have completely demoralized if I hadn't passed all the strength tests with flying colors (I did).

Flexibility-wise, she noted that my hip flexors are pretty tight (my response: "You should have seen them a year ago."), but I was surprised to hear her say that otherwise my flexibility was not bad. Which she clarified to mean: "You are not winning any yoga awards any time soon, but you are also not at risk for running injuries." (And that in fact, in some ways, being more flexible than normal actually puts runners at elevated risk for injury. SO E'RYBODY EASE UP ON TELLING ME TO DO MORE YOGA, A'IGHT?)

My second stop was with my doc, who had the advantage of knowing the intimate details of my entire injury history. He said my feet, ankles, and toes all looked great, that I had excellent range of motion everywhere (this stunned me; I have always thought of my ankles as kind of stiff), and that I had perfectly healthy, neutral arches. He had never seen me run before but based on the footprint test and the wear patterns on my shoes predicted that I would be a mid-to-forefoot striker and that (barring anything concerning in the gait analysis) if they were all comfortable there was no reason I couldn't wear any shoe I felt like. Lately I've been doing the first couple of miles of my easy runs in the PureDrifts to try to strengthen my feet, which he said was fine as long as I continued to increase my time in them gradually & didn't have any pain. (I've had to work up to two miles, BTW, and at that point I definitely feel it.) He did say I carried an awful lot of force on my second & third metatarsels & have significantly larger calluses there, which he'd be concerned about except I've never had any pain or discomfort there. (Much later, it occurred to me to wonder if this was due more to karate than than running. 13 years of scuffling around barefoot on wooden boards has left me with rather more impressive calluses than one generally gets from running.)

My third stop was the gait analysis, which involved getting reflective tape stuck to various joints & then two minutes of brisk walking & then ~10 minutes of easy running on the treadmill (which I did at my normal pace, as opposed to my recent low heart rate pace) while the PT & grad students videotaped & made notes from all angles. Before getting on the treadmill I chatted with the kinesiologist in charge about my issues with my right side, how I was pretty sure I still had an imbalance even though I constantly test strong on both sides. After I finished running, he had me stand on the edge of the treadmill & try doing a few more single-leg squats on both side. No problem on the left, but guess what I suddenly could not do on the right?

My last stop was the sports nutritionist, who was basically like, "As far as I can tell you're doing everything perfectly, except for the things you said you're not going to change." Those things being 1) having wine or beer with dinner most nights, & 2) having pizza or Indian food 2-3 times a week. (Not that I even remotely believe this to be the case, but let's be real--if that's the difference between a 3:36 marathon & a sub-3:30, then screw it; I'll live with the 3:36.) She said I could always get into the nitty gritty details of my individual situation with a standalone nutrition consult & maybe tweak things a little, but I already knew & was doing everything she would have told me in our 20 minute rotation.

After all four runners had been through all four stations, we hung out & chatted for a few minutes while they edited together all our gait analysis footage. Then the four of us & all the experts watched all four videos one at a time and laid out for us step-by-step what they look at, why, how each of us measured up, and what we could do to improve.

(This is where I feel the need to add a bit of a caveat--If you are someone who gets weird about being pubicly evaluated and compared to strangers in an area you're super invested in--like running--you might want to think long and hard about whether RunSafe is the right thing for you, or whether you'd be more comfortable doing a similar private, one-on-one type thing. I have very little experience watching other people run in slow motion, so I found it fascinating to watch people with different strengths and weaknesses than I have and hear what the experts had to say about each of us. But just be aware that it is one of those (metaphorically) standing-naked-in-front-of-strangers-while-they-point-out-every-flaw kind of situations, so if you know that's going to make you uncomfortable or argumentative, maybe do some work ahead of time to prepare yourself to be open to the feedback and gracefully accept what's said without making it weird for everyone.)

Before we started, they were very careful to be clear about something I've heard over and over again from various people who make their livings dealing with runners and their performance / injuries, and that's that when you get in to talking about what is "good" form and "bad" form, you are on very tricky ground. Rather than talking about isolated issues (**coughcoughfootstrikecoughcough**) being good or bad, it's more useful to talk about larger patterns of movement and to what extent they affect performance and injury. Form is, as they say, as form does. (Just look at Paula Radcliffe, the fastest female marathoner ever by a considerable margin. Her form ain't pretty, but it gets the job done.) A particular habit or pattern could be just fine in the case of one particular person, while in someone else, it could be a serious concern because of how it fits in with the rest of their movement patterns.

The other piece of "form is as form does" goes along with the age-old maxim of "if it ain't broke, don't fix it." They don't recommend changing form issues just because they don't fit some ideal template; part of the point of RunSafe is to look at the entire picture, including how a runner's form fits in with their goals and history of injury/discomfort/etc. Some form issues are considered red flags because they're highly correlated with certain injuries, but if you've been running that way for 20 years and never had a hint of that particular injury, trying to "fix" it is actually more likely to cause injuries than just leaving it alone.

There's no way I'll remember everything they mentioned, but here are the high points in terms of what they look for:

From The Rear:

Footstrike. They said generally they get 75% heel strikers, 25% mid-foot strikers, and less than 1% true forefoot strikers. (Apparently everybody THINKS they're a mid/forefoot striker, but slo-mo video don't lie & most land on their heels.) Again, they were very clear that none of these patterns is particularly good/bad/right/wrong, but how you land does affect what else they look for and provide clues to understanding any discomfort/injuries. (For example, heel striking is a concern if you have constant knee/hip pain, and forefoot striking if you've had a bunch of Achilles/calf problems, but not everyone does.) Depending on what else you're doing, any of these strike patterns could be fine or it could be causing problems. Our group had one guy who was a heel striker, one guy who was a true forefoot striker, and then myself & the one other woman who were both sort of halfway between midfoot/forefoot, so statistically we were a bit unusual.

The best shot I could get of my foot strike from the back. Video screen shots are hard.

Pronation. Pronation is how much your foot rolls inward from the time it makes contact with the ground to when it's bearing your full weight. Thankfully, it seems like people are starting to get the message that pronation itself is completely normal & not something that needs to be eradicated with special shoes & inserts & what have you--just about all of us land slightly to the outsie of our foot, then roll in as we complete the stride. On the other hand, pronation that is too extreme can cause all kinds of overuse injuries, and when that's the case you have the option of 1) identifying the foot/leg weakness that's causing it & fixing it, 2) adding a little stability to your shoes in some way, or 3) a little of both. However, we learned that what is MORE associated with injury than degree of pronation is how fast you pronate. That is, where the line from your heel up along your Achilles tendon snaps very quickly from say a 45 degree angle when you first contact the ground to a 90 degree angle as more of your foot lands. (They had reflective tape on these two points to help make that line more visible.) In our group only the other woman had concerningly fast pronation.

You can see how the line of my Achilles tendon changes as I land. Apparently the speed at which my feet pronated was pretty normal.

(***Sidenote:*** I can hear you through the internet shouting, BUT DID THEY SAY ANYTHING ELSE ABOUT STABILITY SHOES??? BECAUSE I HAVE READ THINGS ABOUT THAT AND FORMED OPINIONS!!1!!! The answer to that is a qualified yes, but it's a big topic that kind of goes beyond the scope of this post, so maybe I will write more about that another day.)

Foot angle. This is how much your feet turn out or in. Feet that point straight ahead or that toe in somewhat tend to predict injury because they are associated with knees collapsing in (which usually indicate some sort of hip/core weakness). Apparently the group that suffers the lowest rates of injury are people who run with toes turned out 5-10 degrees (which means that if you're looking from the back, you should be able to see about two toes' width of the outside of the toe box). Our group were mostly normal in this regard, except for one guy who had one foot that could be turned out just a little more.

Note how, if I were barefoot, you could probably see maybe 2 outside toes' worth of my foot from the back when I land. This is one of the things my PT worked on with me after I had my stress fracture, so I'm pretty good at it now.

Stance. Basically this is how far apart your feet are landing from each other. Here, they look for a "knee window" of a few inches of space between the knees. When the stance is too narrow and the knee window begins to disappear, it usually indicates either that knees are collapsing inward (indicating hip/core weakness) or that the feet are crossing over the midline somewhat when they land (which can indicate an imbalance on one or both sides in terms of strength or recruitment of hip/glute muscles vs. adductors & lead to pain in the hips / IT band). In our group the two guys were fine, and both the other woman and I had the crossing-over pattern.

They said they only see the crossing-over pattern in about 15% of runners, so again, it was unusual to have two of us. Mine most likely indicates that I am recruiting more from my adductor & less from my glute med on the right side, which makes a lot of sense.

Cadence. Cadence (strides or steps per minute) predicts injury because lower cadences tend to be related to over-striding (which I'll say more about below). I think they just count it from the back because it's easier from that angle. This is something I've worked on a ton, so I was happy to hear that they had me right at 90-92 strides per minute (ie, 180-184 steps/minute), where they see the lowest rates of injury. The two other more experienced runners where in the low-to-mid 80s, and the one newer runner was in the low 70s. (They actually told him not to shoot for 90-92 just yet & instead try at first just to get up to 80. Apparently making too abrupt of a change in terms of cadence can cause more problems than it solves.)

Pelvic stability. For this, they look at the two dots of tape on your SI joints. Ideally the two stay even, and if one drops noticeably more than the other, it indicates some muscle weakness in the opposite side. I know my right side is weaker and/or recruits less well and that I've always had a drop on my left side, and sure it enough, it was plain as day in the video. Only one person in our group didn't have any drop on either side.

Pretty even when I land on the left leg. On the right side, not so much.

Again, this is one of those things where they were like, "We wouldn't be all that concerned about the difference except that you have recurring injuries on the right side, therefore = problem."

(Also, I just want to say how thrilled I was that apparently this/this is a thing of the past -- no hint of it anywhere in the video, & no mention by any of the experts, so progress!)

From The Side:

Footstrike again. Mostly this is just confirming what it looked like from the back.

This was kind of the clearest shot I could get of this.

Lightness/heaviness/force absorption. This is basically how heavy or lightly you land on your feet & absorb the impact from landing. Light runners absorbing well have very quiet footfalls while those taking a lot of impact up into their bones and joints land noticeably louder (which predicts injury). Myself and one of the guys were categorized as very light-landing, low-impact runners, the one newer runner was considered a heavier-lander, and the other woman was somewhere in the middle.

Overstriding. This refers to where your foot lands relative to your center of mass. If you can draw a straight line up from where your foot hits the ground to your center of mass, you are not overstriding, but if it's out in front at all, you are. Overstriding sometimes predicts injury because landing directly under your center of mass is the most efficient way to distribute & absorb the force of impact, whereas landing out in front of it tends to channel more force up the tibia and into the knees and hips. (Knee pain is a very very common symptom in more extreme overstriders.) All of us had some amount of overstriding.

If I was perfect, that yellow line would shoot right up from my ankle through the pink dot on my hip.

This is a more extreme example, closer to what the one newer runner was doing.

Again, whether overstriding is a problem depends on the rest of the picture. They point it out because it's frequently associated with knee, hip, & back pain because of not absorbing the force efficiently. (Usually the way you correct overstriding is to have people work on cadence; apparently telling them to shorten their strides creates all kinds of new problems). In the case of the two of us with high cadences, light landing, & no history of that type of pain, they weren't worried about it. They were most concerned about the one newer runner who was also a heel striker landing heavily and running with a low cadence

Hip extension. This is exactly what it sounds like--how much do you open the angle of your hip when you push back with your leg? None of us were great at this, and they said that almost everyone they see is bad at it, because we all have tight hip flexors from sitting down all day and not stretching them enough. (The professional athletes they work with, on the other hand, are almost always great at it because they spend so little time sitting & even when they're not training, they're walking around & not being sedentary.)

It's a little bit tricky to pause the video RIGHT at the point where I had the most extension, but I think this was pretty close.

This is something I've been told lots of times & done some work on, but clearly not enough. (I did finally get a real standing desk for work, so I'm hoping that will help some.) They said that to really make any real difference, you really do have to do the hip flexor stretches like 5x a day and make an effort to sit as little as possible. Also, apparently overstriding, low hip extension, and low cadence all seem to go hand-in-hand, ie, if you have one, you usually have the others, and working on one usually helps with the others.

Now THAT is some wicked hip extension.

The biggest takeaway for me was how a little bit of fatigue brings out the muscle imbalance that's still pretty undetectable via the usual PT tests. Most likely, the panel said, crossing over the midline when I run is also a result of not having the endurance on that side that I need (hence my adductor & quad pulling the leg inward). Their main recommendations had to do with my single leg squats. Specifically, a) upping the number of reps per set (I've been doing 2 x 30 on each leg lately instead of 2 x 20, and trying to gradually increase; they said sets of 100 was not an unreasonable goal), b) taking special care that I'm making my glute med do the work, rather than my quad (this is REALLY hard and takes lots of attention; sometimes it's like I can't even get the muscle to fire, period), and c) stopping every mile or two on my easy runs to do EVEN MORE squats on the right side only. (I've been noticing that this is actually a great cue to get the muscle firing when I run. It's always much, much better immediately after stopping for a set, but then gradually wears off. I'm staying at it.) Part of it is also plain old gait re-training: Just try not to run like that.

Bottom Line: Is It Worth It?

I wish I had a super straight-forward answer for your, but alas, my answer to that question is...It depends.

Personally I did not get much out of the PT station, the shoe/foot station (though I learned some interesting things there), or the nutrition station, but that really says more about me and my experiences than it does about the clinicians. For example, I've spent sooooo many hours in PT and had all the strength & flexibility tests so many times that I already know what all my issues there are & am already doing a lot of the things they recommended. I've never had foot or shoe problems (except for the one problem that I figured was related to my right hip, which they agreed it probably is); my doctor was like, "Basically you have great feet & you can run in pretty much whatever's comfortable," to which I was like, "Yeah, I know."

As far as the diet/nutrition stuff goes, imagine yourself sitting down to take an essay exam where the questions are 1) "Explain the basic dietary needs of a normal person (calories, nutrients, etc.) and the factors that affect them," and 2) "Explain how the dietary needs of an endurance athlete are different than that of a normal person (discuss both eating & race fueling), and why." If you feel like you can give solid, reasonably detailed answers to both of these questions, you probably won't learn anything new from the sports nutritionist. On the other hand, if that's not something you've spent hours reading & obsessing about, you might learn a lot.

Far and away the most valuable parts to me were 1) the last half hour or so where we watched all four of our videos & compared them & learned about what the research says about how different aspects of running form predict different types of injuries, and 2) getting some very specific insights and recommendations for my right hip/leg. Was that alone worth the $300? I'm not sure, but I also don't know of anywhere you can get just that for less money. (An individualized gait analysis by one or two people with who-knows-what kind of credentials, yes, but not an entire panel of experts contrasting and comparing four different people.)

So, if you're on the edge about whether or not to spend the money, you really do have to take into consideration what you do and don't already know about your own body and about diet/nutrition for endurance athletes and how much you care about getting the big picture about how form & injury work as opposed to just having someone look at your particular situation. And then of course there's the matter of what else you might need to do with $300. (Ie, four years ago, I needed to, like, buy food and pay my water bill and not default on my student loans.)

For brand new runners who want to be proactive about injury prevention, don't know a ton about it yet, and have the $300 to spend comfortably, I'd say yes, it's probably worth it. For more experienced runners who have had some injury or discomfort issues and haven't already spent thousands of dollars on PT and doctors, it also might be worth it and potentially save you some money in the long term. (If you doubt the possibility of this, we can look at my medical bills together.) Outside of those situations, it's kind of a judgement call in terms of how interesting you find this stuff & to what extent you have access to anything similar.


  1. VERY interesting. Thank you for writing this! I've decided that if I ever get the OK to run again, I'm going to do something like this very early on to get some baseline info on how my body moves and how to fix it. Obviously I'm going to have major right-side weaknesses, so I'd like to know and correct those in a running context from the start.

    I will throw out there that I have done the CPMC gait analysis, which sounds like JUST the PT and gait analysis parts of RunSafe, done privately and with the (probably proportionally accurate) smaller pricetag of $195. I suspect I could learn something from RunSafe's shoe/foot station, maybe less so from the nutrition station as you described, but the benefit of the extra $105 for me might be going into a totally new room with people who don't know the ins and outs of my history and seeing what they'd say.

    One question re: the treadmill. I feel like I run differently on a treadmill than I do outside, so I always worry about doing a lot of treadmill-specific gait analysis that ends up being useless in the "real world." Did they talk at all about that, or is it an issue that is really just particular to me?

    1. I've done gait analysis a few times now, always on a treadmill, & no one's ever mentioned anything about that (though I haven't asked either), so I've always just assume it doesn't affect the stuff they're looking at. (They've always set the incline at 1%, though, which I think is just common practice all around re: approximating non-treadmill running.)

    2. Thanks! I know there's one place in Berkeley (I think) that does outdoor evaluation, and I do wonder if that would be useful, or if it would kind of wreck the science.

  2. Thanks for being our guinea pig and writing this all up! I've never felt especially inclined towards doing RunSafe due to the hefty price tag, even though I am super interested in my biomechanics (yay data!). On a related note - my former boss started a company that's using the Xbox and reflective tabs to analyze movements, especially in the PT/clinical setting. They're starting with single leg squats and box jumps, but eventually want to be able to track more complicated motions such as running. I assume with that kind of technology, the cost of these RunSafe-type programs will come down, since the software will analyze your data for you.

    So did you come away with anything else besides doing hundreds (!!!) of single leg squats?

    1. Heh, that could be really cool! Yeah, the price tag is definitely a detractor.

      So that was one of my frustrations about it -- the recommendations were not very specific, and pretty much limited to stuff I've been doing hundreds of times a week for years. I have to say I was not impressed by that.

  3. All I can focus on is where you mentioned that not everyone likes being 'pubicly evaluated'. (The paragraph next to the photo of the person in the blue skirt with the guy evaluating her...pubis?)

    Made. My. Night.

  4. Now I've stopped giggling...this is all fascinating stuff. Did they mention anything about what to do if you're a heavier-landing runner? For all my being 5'1, I land like a rhino and wear away shoe cushioning pretty quickly. I've been very lucky not to really get injured but I'd be intrigued to find out if there was anything else I should know about that particular characteristic?

    1. The recommendations were all individualized in our little packets, so they might have written stuff for the people who had those issues, but they didn't mention anything specific with the whole group. In other settings, I've heard things like box jumps (jumping up and jumping down) & focusing on landing silently, and also jump-roping, progressing from normal, to double-unders, to one-legged.

    2. I will say - the jumps in ballet do teach you to land VERY lightly! (One of my running friends is taking an adult beginners ballet class now, and it's making me miss ballet hard-core; it's fascinating to hear articulated from an adult runner's perspective all the things that I learnt as a little baby bunhead before I had the language skills to understand them.)

  5. Thank you for this article!! Will be useful for me. I realize that I'm heel striker, even I try to landing with my midfoot so I have a question about your shoes: you usually use running shoes with low drop ? Because my shoes have 12mm drop ( mizuno wave rider16) , and those shoes don't help to avoiding heel strike.

    1. I think right now all of my shoes are 4mm except Brooks Launch, which is 10mm. I definitely find that for me, a larger heel drop gets in the way. I'm not inclined to heel strike, generally, but I have heard from people who are trying to transition into more of a mid-foot strike that (GRADUALLY) transitioning to a lower drop shoe has helped them break the habit. Other things I've heard is working on not over striding, leaning forward from your hips, and adding speed work (since the faster you run, the harder it is to heel strike).

  6. Thanks for the very extensive report! I think with things like this, software data analysis can get you *some* of the way, but as with all healthcare, human experts will be needed to evaluate the individual client.
    Also, I'm curious about this in particular because it's an issue I have too - how do you tell if the gluteus medius is firing while you run? Can you describe what that *feels* like? How do you consciously attempt to make sure it is working?