Pain-Free Running: A PT’s Guide to Hip Health for Distance Runners

Running is the most common competitive exercise goal I’ve seen patients pursue during my 10 years as a PT. It’s relatively easy to do at any age, experience level, and ability. You can be as flashy or simple as you want in terms of gear and you don’t need any equipment making it accessible to the masses.

Because it’s an easily accessible sport, novice (and sometimes even experienced) runners end up doing too much, too soon, after doing too little for too long. This can lead to a variety of injuries in runners ranging from ankle to back and even sometimes neck and shoulder pain.

Today, though, we are talking about hip pain in distance runners.

With any movement related problem, whether it is pain, limitation, weakness or even stiffness there are a few principles I focus on to provide optimal outcomes and help my patients understand their pain.

1. What does ideal running look like?

First, what does ideal running look like? What is required of a runner to be good? Comparing yourself objectively to that criterion movement gives you clear ideas on what needs to be improved.

2. Why is that movement lacking?

Is it a range of motion issue, a strength deficit or both? The answer to this question shows us what avenue of treatment to pursue.

3. Fill the Gap!

At this point, we work toward diminishing your difference between ideal movement and current movement.

4. Consider the WHOLE person

We also never want to forget the person for who they are and what makes them love their sport. Distance runners are a VERY different breed.

Running Gait: A Breakdown

Let’s break down the pattern and manner in which a person runs, often referred to as their running gait.

The primary engine of a runner comes from something called triple extension. This includes full and powerful extension at the hip, knee, and ankle so that the runner produces maximum force through the earth and propels themselves forward.

I find excellent examples of triple extension in action watching runners like Jackie Joyner-Kersee, Allyson Felix, and my favorite from the 2024 Olympics, Sydney McLoughlin-Levrone.

But these are all sprinters, and the running pattern of a sprinter is somewhat different from that of a distance runner.

A distance runner (or “marathoner”) takes anywhere from 50,000 to 60,000 steps in their race. A sprinter typically takes 230 to 250 steps in a 200 yard sprint. So why’s there a difference in gait? There has to be! Can you imagine doing anything for 24 hours? Well, I couldn’t either until I had a client who wanted to complete a 100 mile race in Leadville, CO. Not only did he want to run a race at the point of highest altitude in the state but he wanted to complete it in under 24 hours. Like a day. A full day! Doing anything for that long means that it probably won’t look perfect.

Looking Closely at the Hip Joint

Let’s take our analysis one step further and look directly at the hip joint. This is one of my favorite joints because it truly affects so many other areas of our body above and below it.

The hip joint moves through every plane of motion: front to back, side to side, and rotationally. But with every movement also comes the valuable ability to prevent movement, or what we call stabilization.

Stabilization is important at the hip during running because it prevents poor lower leg mechanics.

In the graphic below, the hip on the left is stabilizing well by preventing the pelvis from dropping and keeping the leg in a neutral posture. The hip on the right is not stabilizing well so the pelvis is dropping, causing the knee to fall relatively inward and the foot to collapse.

You can imagine, if you run a marathon and take 50,000 to 60,000 steps with poor mechanics, something is bound to hurt and you probably won’t produce your best triple extension force.

Knowing all of this background information gives your physical therapist a good idea of where and why your form may break down and how it impacts your pain.

Your Physical Therapist’s Role

The breakdown of perfect form with distance running will happen due to weakness or limited mobility relative to the demands of the task. Without addressing this weakness or immobility, you can treat the pain but it will return if the demands of running continue.

To simplify it, your physical therapist should either be WD40, duct tape, or a combination of the two. By addressing the limitations that lead to your pain, we prevent that pain complaint from returning.

Your Physical Therapist is Duct Tape

Most commonly, your PT will need to be duct tape. Without the appropriate amount of strength, a simple way to think about things is that sometimes the client moves too much. Weakness in hip musculature is shown in the graphic from earlier where the runner on the left demonstrated pelvic drop, an inward falling knee, and a caved in foot. This movement can be controlled with appropriate strengthening.

A study by Youdas and Loder showed that only 45 seconds of resisted side stepping with an elastic band imparted a statistically significant change in the position between the pelvis and femur [1]. If just 45 seconds of one exercise can make a change in lower limb position, that tells me the muscle is firing in a more productive manner!

Your Physical Therapist is WD40

When someone is tight, has limited mobility, or muscle and joint issues that cause pain we become your WD40. That’s right, the greasy stuff you put on a bike or door hinge to stop the squeaking. Imagine standing with your arms over your head and leaning backwards. If this movement is limited, it may be due to tight muscles on the front of your body preventing you from leaning backward. In this instance we work to get the anterior hip moving better, like WD40.

All of these concepts are great in theory but seeing an example in action should bring the concepts full circle.

Theories put into Practice

A marathon runner presents with pain in the front of their hip that occurs after approximately 5 miles of running and then becomes intermittent beyond that distance. The runner also complains of pain after running for the remainder of the day. During testing, the PT looks at the client lean backward with their arms reached overhead. They demonstrate pain and limited range of motion with this movement. Further testing demonstrates tightness in the front of the hip and difficulty demonstrating full hip extension because of that tightness. When the runner’s gait is assessed, they are taking short strides with increased hip and knee flexion. Instead of generating triple extension they are forcefully pulling the hip and knee forward into flexion or a stepping style of gait.

Get it Moving Better First!

Pain should be addressed first otherwise the runner will compensate during the remainder of the interventions. The pain can be treated in a variety of ways. It may be through trigger point work, manual stretching, contract relax techniques or, my favorite intervention, dry needling. But your PT is going to pull out whatever variety of WD40 they practice. After WD40 is used you’ll be encouraged to do stretches like those shown below to keep the mobility you have gained. This will help to address the limited mobility in the anterior hip that led to the patient’s pain in the first place!

Now What? 

So you found the best PT ever that helped you address your pain and normalize your movement. Here is where my strength and conditioning brain kicks in and, if you are a fan of Game of Thrones, where I think of Hodor.

Each runner has the option of two paths: 

Option 1: If you do not vigilantly work to remain strong, mobile, and agile, you will be working with a thin, plywood door, and a short skinny 120 pound pre-teen. .

Option 2:  You build up a door that is five inches thick, bolted shut with several locks, reinforced with cinder blocks and backed up by Hodor who has been working out, eating his protein, and is feeling extra stubborn today.

The first scenario will apply to that runner who gets their hip treated and a little stronger but does not keep strengthening long term.

The second option applies to endurance athletes that continue to work on being strong, stable, and mobile in the right areas so that they are able to hold that door shut or keep pain at bay deep into their long distance race season.

Resilience is KEY! Balancing your running with strength training throughout your season may seem like a big time burden but it staves off pain and injury which is the key to success.

Consider the Athlete’s Psyche 

Before we wrap up, take a moment to reflect on yourself as a runner.

Most distance runners can recognize that they are a different breed of athlete. As a sprinter, it was always difficult for me to relate to the mindset of a distance runner. If I was sprinting and I experienced pain in my leg, I most likely injured something.

A distance runner is different. For them, pain is somewhat normal. While pain is anticipated with distance running, some athletes take this too far, push past it, and end up prolonging the time they have to take away from their sport in order to recover.

I encourage all distance athletes to learn more about normal and abnormal pain and how to manage it. Pain management can range from strategies like getting enough sleep, proper nutrition, movement recovery techniques, adapting your training schedule, or seeking out a PT. Ignoring some “small” pains could result in big problems.

Most Importantly! 

Most importantly, I encourage you to make it a priority to find a physical therapist and make them part of your trusted health care team. They should value your time and their craft by working in a setting that allows for one-on-one care. Whether it is a MovementX provider or someone else, physical therapists like this will get you better, faster because they have a complete session to give you undivided, quality care. If you need help finding a provider like this, don’t hesitate to reach out to us! We would love to help.

References

1. Youdas, James, Loder, Erica. (2006). Hip-Abductor Muscle Performance in Participants after 45 Seconds of Resisted Sidestepping Using an Elastic Band. Journal of Sports Rehabilitation. 15(1):p 1-11. https://journals.humankinetics.com/view/journals/jsr/15/1/article-p1.xml?content=abstract

2. Lorenz, Daniel. (2016). Triple Extension in Rehabilitation. Strength and Conditioning Journal. 38(1):p 48-50. https://journals.lww.com/nsca-scj/fulltext/2016/02000/facilitating_power_development_in_the_recovering.7.aspx