Table 6

Expert opinion related to practical implementation of proximal retraining strategies

Illustrative quotes
Trunk and pelvic position
Various cues and beliefs related to trunk and pelvic position changes“We would use a variety of cues to try and get the torso as upright as we can … resting your chin on the top of a wall whilst running and trying to imagine a hook through your nose lifting your head up to try to maintain that body position (can help a runner be more upright).” (7)
“I'll be looking at sort of pelvic drop, rather than necessarily anterior posterior pelvic position per se … try to get them to focus on a high pelvis on the opposite side. So on the swing leg, so they're not letting it drop as they run.” (12)
“Cueing around lengthening spine, lifting chest, their sort of upper body postural shoulder girdle cues to get their core engaged, to get their pelvis stabilised and straightened up and to get them pushing their centre of gravity forward over their foot … That usually fixes all of the (running technique issues).” (13)
“Tell them to stand up taller, they'll stop over striding and they'll hit the grounds more times per minute (ie, increase step rate).” (14)
“Anterior pelvic tilt is hard and I tend to work (on correcting this) before I even get them up on the treadmill and gait retrain them, I tend to work on a more on a static position, so running in place, bridging. Trying to work on high knees, even getting into a plank position… Feel what it's like to have it in posterior pelvic tilt, have a tight abs and tight gluts, but then still be able to turn their feet over and then try to transfer it over to the treadmill.” (14)
“I haven't addressed forward lean (as part of running retraining). I haven't seen a lot of leaners in my experience.” (15)
“I will usually go through a process of giving people a sense of being tall and what that feels … I might talk about people being lifted by the top of their crown so they have a sense of tall … Once I've got people in that sense of tall—I'll either talk to people about being lifted up and slightly forward through the crown of their head or I will talk to people about subtly leaning forward from their ankles.” (16)
Visual and verbal cues to reduce hip adduction
Considerations and varying methods to change transverse/coronal plane hip and knee kinematics
Changing pelvic, hip and knee mechanics in the frontal/transverse plane through increased step rate and sagittal plane changes
“I've been working more on external focus of push their knees outwards (to reduce hip adduction) … It seems like the runners tend to get it much faster … They don't start getting some of these maladaptations that I saw previously when I had people really squeeze their glutes a lot.“ (2)
“Their squeezing their buns and trying to get their knees apart (to reduce hip adduction) … you look at it frame by frame you can actually compare their pre and post and see a little more space between their knees so we give them that feedback.” (4)
“If I'm trying to change someone's femoral adduction, it will be something like try and maintain some distance between your knees.” (5)
“Trying to get them to think about tightening their glutes, sometimes think about tightening through their core (to reduce hip adduction and internal rotation.” (6)
“I usually start with sort of—kind of the usual ones (to reduce hip adduction) … keep your knees apart, you can say squeeze your buns … tell them to focus on something outside the body … your knees are headlights, your knees are flashlights, keep them pointed straight ahead.” (8)
“Look at what happens at the hip and the knee to make sure that they're actually creating it (space between their knees) by reducing hip adduction and internal rotation, rather than just bringing the feet apart and keeping their knees quite pinched in.” (12)
“would use mirror training (to reduce hip adduction and internal rotation). Other cues, I would kind of cue them to try to tighten the gluteals.” (15)
“If you increase the cadence, you don't have much time to collapse your knee in, you don't have much time to do the pelvic drop, so I work a lot more with that.” (1)
“When we change sagittal plane kinematics, we notice a change in frontal plane kinematics (of the hip) as well.” (9)
“I mean, my experience again, it seems everything comes back to cadence … if we can improve that cadence by ten to 20 percent from the baseline level, then that usually looks after what's going on with (hip) internal rotation adduction, unless it's related to crossover gait.” (11)
Increasing step width/hip abduction at foot strike
Step width considerations and potential benefits“Sometimes (a narrow) step width is an issue, you know, if they are crossing over for example, if they are scissoring, I'll give them some cues on foot placement, trying to run on a line or outside of a line (to increase step width).” (8)
“You often get an affect of being quite narrow with the stride width on the rest of the chain. So you often see that (narrow step width is) accompanied by a hip adduction and maybe hip internal rotation.” (12)
“You just have to be careful (increasing step width) because you don't wanna go too wide because you can create a whole new set of other issues … When they're running occasionally on a treadmill it works a bit better to give them either a mirror or sort of cue them to sort of land with their feet a little farther apart, maybe more underneath their hip as compared to underneath their belly button, that cue has worked well (to increase step width).” (15)
“Sometimes I will cue people to “Imagine that you're running on a train line. You wanna keep your feet a little bit wider,” particularly if they have that negative cross over gait.” (16)
Cues to increase hip extension
Hip extension considerations“You've gotta give them the underlying strength and flexibility in that terminal extension range … get them to drive through their hips when they're running. So drive through your hips so really try and extend your hip when you're running and that works (to increase hip extension) for some people.” (5)
“I tend to find if I ask people to actively extend their hip, then all they do is overextend their lower back and it doesn't tend to lead to positive change in the gait pattern, whereas if I ask them to apply positive downward pressure into the treadmill or the ground, they tend to get a nice hip extension that's appropriate for the speed of running.” (11)
“I do think if the extension is a tricky one to restore … I think you can do it by actually encouraging the patient to flex at the hip more, and as a consequence to that, they tend to naturally extend their hip more … but also they want to look at making sure they've actually got the range in the first place, if there is any restriction in the hip joint extension, or tightness in the hip flexor region, that's going to make you very difficult for them to get any extension.” (12)