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6/16/2020

Learn How Your Feet Can Prevent ACL Tears

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Reduce The Likelihood of ACL Tears By Optimizing Your Foot & Ankle Biomechanics

Introduction
Anterior cruciate ligament (ACL) injuries are a major frustration for athletes. Especially frustrating is that 70-84% of all ACL injuries are non-contact(1).  

Even in today's innovative world of surgical interventions and rehabilitation, an ACL injury can sideline an athlete for months to years. On top of this, only 50% of athletes return to play after a year of being sidelined and only 65% return to play after 2 years of being sidelined(3).
 
What To Expect From This Article
You will learn about modifiable risk factors at the ankle and foot complex and get strategies, including exercise videos (scroll to the bottom of the article), to help reduce the likelihood of an ACL injury. 

Although the ankle and foot complex is a big deal when it comes to ACL tears, there are a lot of other risk factors that contribute to ACL injury. In future posts, you will learn about how problems at the knee, hip, and trunk influence ACL integrity.

What Is The ACL & What Does It Do?
Simply put, the ACL is a ligament that stabilizes the knee. 

Because the ACL attaches from the medial-posterior side of the lateral femoral condyle and connects to the center of the tibia plateau, it helps control anterior translation of the tibia and rotational forces of the tibia, particularly when the knee is in 30 degrees of knee flexion or less(5). The ACL also helps resist valgus stress (knee abduction) and to extreme degrees, varus stress to the knee.
 
So What Does The Ankle and Foot Complex Have To Do With The ACL?
The ankle and foot complex assists the ACL in its job to decelerate anterior tibial translation, tibial rotational forces, and tibial abduction.  

Let’s explore the ankle and foot complex in detail to better illustrate why the ACL needs this complex to work exceptionally well.
 
What Does The Ankle and Foot Complex Do?
Impressively, the ankle and foot complex accepts loads of about five times body weight just with walking and around thirteen times body weight when running! All the more impressive is that the ankle and foot complex is less susceptible to osteoarthritis than the knee or hip which both experience less impact forces than the ankle and foot complex(4). 
 
To put it simply, the function of the ankle and foot complex is to deform in a controlled manner to accept load (pronation) when the foot first hits the ground and to take form and become rigid (supination) to push off the ground. 
 
Here’s How the Foot Pronates and Supinates in Complex Detail and How it Ties into the ACL
When pronation occurs at the ankle/foot complex, we get forefoot inversion in the frontal plane, midtarsal dorsiflexion in the sagittal plane, and forefoot abduction in the transverse plane. Essentially, the forefoot moves in a way that allows optimal load acceptance which reduces impact forces. 

The opposite is true for supination at the ankle and foot complex in order for the foot to become rigid to push-off of. So under normal circumstances the foot pronates or becomes a bit malleable when the foot first hits the ground. This allows the foot to absorb load to store potential energy which is then used to make the foot rigid (supinate) to push-off the foot from mid-stance to late stance phase while walking or running.

The mechanism that allows the foot to become malleable to store energy and to become rigid to push-off is at the subtalar joint. The subtalar joint has three interfacing condyles that are situated between the calcaneus and the talocrural (ankle) joint and they play an important role in unlocking the foot for successful pronation which then drives tibial internal rotation. 

During forefoot push-off, the three interfacing condyles of the subtalar joint, likewise, orient themselves in a way that allows the foot to become rigid and for the tibia to externally rotate. This is why the subtalar joint is known as the torque converter because of its ability to convert frontal and sagittal plane motions at the foot to drive rotational forces up the chain.

This concept is important because the torque converter of the subtalar joint causes the tibia and femur to rotate internally (turn in), and for the knee to abduct (fall in), and it also influences anterior pelvic tilt - all of which are critical to engaging the glute!

It is the rotational forces that occur at the tibia as a result of foot pronation that stimulates the proprioceptors of the ACL to engage the surrounding muscles to help stabilize the knee in order to keep the knee within its normal axis of rotation.

The Ankle and Foot Complex,Tibial Translation in Complex Detail, and How It Ties into the ACL
When the foot first hits the ground, the foot stays fixed in place which allows momentum to carry the tibia forward in the sagittal plane. This action is known as anterior tibial progression (different from anterior tibial translation). In our definition, tibial translation is the shearing force that occurs between the femoral and tibial condyles at the knee. 

It is important to understand the distinction between the two because when tibial progression occurs during early to midstance phase of gait, it is often accompanied with a degree of knee flexion. The knee flexion moment that occurs during the initial stance phase of gait allows the femoral condyles to rotate or spin posteriorly in the sagittal plane. 

When posterior rotation occurs at the femoral condyles, relative anterior translation (anterior shear) of the tibia occurs which lengthens the ACL and turns on its proprioceptors -  this proprioceptive activation is what sends information to surrounding muscle groups to help decelerate the anterior tibial translation and thereby protect the ACL.  
 
Ankle and Foot Complex Issues That Contribute To ACL Tears
Now it’s time to look at modifiable risk factors of the ankle when it comes to non-contact ACL injuries.
 
Excessive Foot Pronation
Excessive foot pronation in an athlete can place excessive stress on the ACL in the transverse and frontal plane. Excessive pronation on impact (when the foot hits the ground) places an excess amount of transverse force on the ACL and, over time, reduces the integrity of the ACL.

In a similar manner, stress on the ACL increases when pronation occurs beyond midstance during gait.  This keeps the knee in internal pronation and abduction for too long which means the ACL is under tension for an excessively long period of time.

Uncontrolled Anterior Tibial Translation
Uncontrolled anterior tibial translation places excessive stress on the ACL primarily in the sagittal plane. More often than not, the hamstrings and calves are the primary muscles that fail to help decelerate anterior tibial translation.

Uncontrolled Knee Abduction
Uncontrolled knee abduction also places excessive stress on the ACL in the frontal plane of motion. The attributing factors to uncontrolled knee abduction are often a combination of reduced lower core, glute, and strength in the foot.

How Do Ankle & Foot Complex Issues Relate To An Athlete?
An athlete is most vulnerable to a non-contact ACL injury when landing from a jump or when performing cutting or pivoting motions(3).
 
Athletes that land on both feet from a jump with excessive subtalar foot pronation put themselves at an increased risk of ACL injury due to excessive tibial internal rotation - this means more time under tension for the ACL (think too much time spent decelerating pronation). 

An athlete will be at an even greater risk if they land on one foot with excessive subtalar foot pronation. This is because of the added mass and momentum of impact from landing on one foot. 

Repetitive jumps with poor landing mechanics at the ankle/foot complex in a game, over a season, and over an athlete's career,  will cause repetitive strain to the ACL and, worst case scenario, a full rupture.
 
Pivoting and cutting motions have a similar effect of causing excessive strain to the ACL when the athlete has poor foot pronation control. If the supporting leg has excessive foot pronation, it results in the tibia placing excessive load on the ACL. Again, when cutting and pivoting motions are done repetitively during a match or throughout one's career, it increases the athlete's risk of straining or tearing the ACL.
 
The secondary risk factors that can feed into excessive foot pronation are reduced ankle dorsiflexion and excessive first ray dorsiflexion. The body always finds ways to complete the task at hand even at the expense of less optimal, compensatory motions - this is why secondary risk factors may feed in excessive foot pronation.
 
When an athlete has limited ankle dorsiflexion, it may start tasking the subtalar joint and midtarsal joints to move through more eversion and inversion motions respectively (these are both components of foot pronation). This is your body’s attempt to increase potential energy of the posterior lower leg extremity muscles (gastrocnemius, soleus, posterior tibialis, fibularis muscles). The compensation’s goal is to help decelerate tibial motion that would usually be directed through ankle dorsiflexion. Increased subtalar eversion and forefoot inversion will influence the tibia to increase its internal rotation moment, exposing the ACL to new ranges of stretch that it may not be able to control without training or support from other systems.
 
Likewise, excessive dorsiflexion of the first ray puts the ACL at a similar risk of injury. Excessive dorsiflexion of the first ray during stance phase of walking and running influences the torque converter mechanism of the subtalar joint which results in excessive tibial internal rotation. This will increase the ACL’s time under tension  which means excessive stretch and increased likelihood of injury. 

The Hypomobile Foot
A foot that remains in supination when landing or performing cutting and pivoting motions can reduce the integrity of the ACL. If the foot remains in supination, the ankle and foot complex’s ability to absorb load diminishes, forcing the knee and hips to accept more impact. Cutting and pivoting motions with an ankle and foot complex that remains in supination will put an increased amount of stress on the knee structures, including the ACL. 

A supinated foot can actually load the ACL via tibia external rotation with same side cutting and pivoting motions, as the ACL will attempt to assist other passive structures to decelerate external rotation at the knee (the femur will internally rotate faster than the tibia now that the rigid foot blocks normal pronation from occurring). Again repetitive movement patterns like these places an increased amount of stress on the knee and ACL.
 
Fatigue To Ankle Muscles
Fatigue plays a huge role in neuromuscular control of the ankle and foot complex and has been found to increase the risk of an ACL injury(1,2). When the muscles of the ankle and foot complex begin to fatigue (gastrocnemius, soleus, posterior tibialis, fibularis muscles, and intrinsic muscles of the foot), these muscles begin to lose their ability to decelerate motions of the ankle and foot complex which then results in increased tibial internal rotation and abduction of the tibia which leads to increased time that the ACL is under tension - this means greater risk for ACL tears. 
 
Strategies To Reduce The Risk Of ACL Injury Related To Ankle and Foot Complex Issues
Intervention programs that include multiple components (your biomechanics profile, dynamic balance, strengthening, stretching, body awareness and plyometrics) are the most effective way to help reduce ACL tear risk factors related to the ankle and foot complex(2).
 
Checkout the exercises below to help optimize your ankle and foot complex biomechanics while reducing the risk of ACL tears. 

Studies show that preventative exercises can decrease non-contact ACL injuries by 52% in females and 85% in male athletes when done correctly(3)!

ACL Injury prevention: 3D Calf Stretch


ACL Injury Prevention: Ankle Dorsiflexion & Pronation Range of motion


ACL Injury prevention: foot & ankle stability drills


ACL Injury prevention: ankle & Foot Strength (Flat feet focused)


ACL Injury prevention: Ankle & Foot based plyometrics


Conclusion
To prevent an ACL injury, the ankle and foot complex needs the optimal amount of mobility and stability throughout the subtalar, talocrural, and midtarsal joints that in turn influences motions of the tibia. Being attentive to these motions that you or your athlete lacks or have in excess and addressing them with the appropriate exercises will go a long way to prevent an ACL injury.

​PROFESSIONAL INJURY AND BIOMECHANICS ASSISTANCE
​
If you need help recovering from an ACL injury or would like to reduce the likelihood of an ACL injury, let one of our ACL specialists help you move and feel better!  Call us at (206) 279-2870 or email at hello@forefrontpllc.com.  You can also schedule a visit online here.

ABOUT FOREFRONT PHYSICAL THERAPY
Most people never fully recover after an injury because they aren't getting the care they need.  At Forefront Physical Therapy, we ensure a full injury recovery by individualizing your care so you can move better and enjoy a pain free life.

​DR. Manny Acheampong, DPT, FAFS
​
Forefront Physical Therapy
Belltown & South Lake Union
Seattle, WA
www.forefrontpllc.com

References
  1. Alentorn-Geli, E., Myer, G. D., Silvers, H. J., Samitier, G., Romero, D., Lázaro-Haro, C., & Cugat, R. (2009). Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 1: Mechanisms of injury and underlying risk factors. Knee surgery, sports traumatology, arthroscopy, 17(7), 705-729.
  2. Alentorn-Geli, E., Myer, G. D., Silvers, H. J., Samitier, G., Romero, D., Lázaro-Haro, C., & Cugat, R. (2009). Prevention of non-contact anterior cruciate ligament injuries in soccer players. Part 2: a review of prevention programs aimed to modify risk factors and to reduce injury rates. Knee surgery, sports traumatology, arthroscopy, 17(8), 859-879.
  3. Acevedo, R. J., Rivera-Vega, A., Miranda, G., & Micheo, W. (2014). Anterior cruciate ligament injury: identification of risk factors and prevention strategies. Current sports medicine reports, 13(3), 186-191.
  4. Brockett, C. L., & Chapman, G. J. (2016). Biomechanics of the ankle. Orthopaedics and trauma, 30(3), 232-238
  5. Domnick, C., Raschke, M. J., & Herbort, M. (2016). Biomechanics of the anterior cruciate ligament: Physiology, rupture and reconstruction techniques. World journal of orthopedics, 7(2), 82.

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12/26/2019

PERFECT YOUR STANDING BOW WHILE PROTECTING YOUR HAMSTRINGS

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Standing Bow - A complex & challenging Pose

In the past year, I have worked with several individuals who hurt their hamstring while performing standing bow. There is nothing wrong with this yoga pose - in fact, the standing bow is incredibly beneficial to your balance system, core strength, hip flexibility, and spinal mobility. Those benefits could be said of many other yoga poses, but the complexity of standing bow makes it unique in its physical requirements and ultimate benefits.
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Standing Bow Pose

Biomechanics behind a standing bow hamstring injury on the lifted leg:

Oversimplified, limited hip flexor flexibility is often the main cause of a hamstring strain on the lifted leg side. If your psoas and iliacus are tight (hip flexors), then the moment you pull your foot up behind you is the moment your body will compensate.

Here’s the more complex answer...

As the leg is pulled back, with the assistance of the hamstrings, the hip should move a lot - especially as you sink into the pose and pull your foot farther up and back. If the hip flexors are tight, your low back will hyperextend instead (this ends up driving a greater degree of anterior pelvic tilt).

A hyperextended back also creates compressive force on the little facet joints in the spine which results in a smaller space for the nerve roots to exit the spine.  This means reduced neural input to the lower extremities. 

If you couple the low back’s hyperextension and excessive anterior pelvic tilt with a hamstring working in an overall shortened position against a strong opposing force (hip flexors), you set yourself up for a high hamstring strain.  Interestingly, the hamstring lengthens near its origin as a result of the anteriorly tilting pelvis which further adds to the muscle strain.

Biomechanics behind a standing bow hamstring injury on the stance leg:

Again, we can oversimplify the cause and blame a high hamstring strain of the stance leg on limited hip flexor flexibility on the lifted leg.  As the pelvis rotates too far anteriorly, the hamstring origin of the stance leg tensions too much which can result in a tear.  

Usually, the hamstring tears on the stance leg not because of limited hamstring flexibility but because of limited hip flexor length and hamstring, glute, and abdominal strength - there is often an inability to decelerate (control) the pelvis tilting anteriorly.

Side note regarding hamstring strains on the stance leg:

The hamstrings are often not taught to use and control their flexibility during significant hip abduction as required for the stance leg during standing bow.  Additionally, uncontrolled hip internal rotation and foot pronation can cause hamstring strains.

So how do you perfect your standing bow and protect your hamstrings?

Address three biomechanics pieces to optimize your Standing Bow:

1. Hip Flexor & Quad Flexibility

2. Lower Ab & Hamstring Strength

3. Thoracic Spine Extension + Rotation Mobility

Not only will the above exercises keep your hamstrings protected, they will also keep your low back healthy while improving your ability to perform your standing bow.  And they will make your standing bow look and feel much better!

​Professional injury and biomechanics assistance

If you need a biomechanics analysis or are experiencing pain while doing yoga, let one of our expert physical therapists help you move and feel better!  Call us at (206) 279-2870 or email at hello@forefrontpllc.com.  You can also schedule a visit online here.

About Forefront Physical Therapy

We help rescue people from injuries that stop them from doing the activities they love.  And we do it through activity and individually specific exercises. All of our physical therapists are trained in Applied Functional Science which allows our patients to experience more authentic success in their movement related recoveries.

​Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy
Belltown & South Lake Union
2720 4th Ave Ste 115
Seattle, WA 98121
www.forefrontpllc.com

​Schedule An Appointment Online

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7/8/2019

Need to Get Your Body Moving & Feeling Better?  Forefront's New Physical Therapist Will Help!

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Enjoy life with a body that moves & Feels good! 

PictureClick the image for Manny's bio!
With a strong background in athletics and human movement, and with the biggest caring heart you'll find, Dr. Manny will help guide you back to healthy, pain free living in the most challenging yet thoughtful way possible. 

He has a genuine interest in seeing his clients succeed and become heroes of their own body.

​He will initially be seeing clients at both of Forefront's Belltown and South Lake Union locations, and will transition to full-time in South Lake Union in the next 6-12 months.


To schedule appointments with Dr. Manny Acheampong and to take control of your pain and movement, call (206) 279-2870 or email hello@forefrontpllc.com. 

Manny has had his share of injuries in the past and knows what it takes to get back to pain free activity.  He will help you become the best version of yourself and enjoy life with a body that moves and feels good!


Forefront Physical Therapy
Movement For A Healthy Life

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1/21/2018

How to Crush the Columbia Tower Stair Climb - Stairwell Training & Strategies (Part III)

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Achieve your fastest stair climb possible with these strategies

By: Dr. Dan Benson, DPT, OCS, FAFS
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If you successfully worked on the mobility and stability training drills as well as the functional stair drills from the first two blog posts, then you are ready to fine tune your training.  

It’s time to go in-depth regarding stair climbing strategies and biomechanics! 

How many stairs to take with each step

Ideally, you should be doing two stairs at a time.  To assist with carrying momentum, try stepping onto the first stair of each flight and then continue with the two stair strategy thereafter.  This will also help you conserve energy because you will not overly stress yourself to “jump” to the second stair after turning at the landing between flights of stairs.

Be efficient at the stairwell landings - keep your steps to two or less during the transitions between flights of stairs.


How to integrate arms

If you have the stairwell to yourself, use both handrails!  Just like with walking, your arms should be moving in opposition to your legs - this is critical to help stretch and activate your core and glutes.

However, as you round the corner at a landing, try stepping your left foot onto the first stair of the next flight and reaching for the left handrail with your left hand - you can take advantage of centrifugal forces and swing yourself up the stairs of the next flight with your left arm!  Just make sure you get a solid grip with your left hand…

When you are sharing a stairwell and you are passing a fellow climber or you are getting passed, you should be using one handrail with both arms.  Although less ideal, both arms pulling via one railing is still incredibly helpful.  

As a note, please be considerate of your fellow climbers.  If you are being passed, please be sure to step toward the outside of the stairwell to allow the faster climber to pass on the inside.

Pre-race warm up

The big climb will spike your heart rate throughout the race.  As such, you should make sure your heart and legs are prepared before you get to the first stair.  Try the moves below to get your heart rate going and legs and arms functionally warmed up.

Stairwell drills

Although the ideal is to take two stairs at a time, you should practice doing one stair at a time sporadically during your climbs.  This is important because there are times when there will be bottlenecks or you will be trying to pass fellow climbers and you will not be able to climb using the “ideal” technique.  

Additionally, some training in which you take three stairs at a time is a great strategy to functionally improve hip and foot flexibility.


Most of your stair training days should include a variety of drills as shown in Part II of this blog post series.  However, up to 1x/week or once every other week, you should be doing a “speed day” in which you are specifically climbing the stairs as if you were doing the actual Columbia Tower race.  Make sure you train as if there are other racers in the stairwell so that you are not climbing “perfectly” throughout the climb (use the two hands on one handrail strategy intermittently or pretend like you are passing another climber and can only take one stair at a time).

Heart rate training

Ideally, you should chat with your physical therapist before attempting a stair climb to ensure your heart is up to the task.  If you know your cardiovascular system is safe for this strenuous competition, then you should optimally train your heart to prepare for the challenge.

Check the numbers.  Time how long it takes you to climb 23 flights of stairs, or some other close derivative of 69 flights - this should be calculated based on climbing at a relatively intense, but sustainable pace.  Once you are able to estimate what your 69 flight climb time could be, you need to plan some workouts around that duration.

For example, let’s say you calculate that it will take you 15 minutes to climb the Columbia Tower.  Then you need to do some sort of cardio at least 1-2x/week, at a relatively intense level for 15 minutes.  The training should be done in a stairwell or on a staircase at least 1x/week.  You may want to add an extra 1-2 minutes to your “relatively intense” cardio workouts to build in a buffer in case your calculations were off or the race simply ends up being harder than expected. 

Elevator drills

If you have the option, use the elevator to go down!  Although it is important to learn to control your knees when descending stairs, you can reduce some of the stress associated with stair descents by using the elevator instead.   

However, given that you do not actually get a rest break during the climb, you should not be resting while waiting for or while riding the elevator to get back to the bottom of your building’s stairwell.  

When you get to the top of your building’s stairwell, the last thing you should do is stop moving.  Keep your heart rate up!  To make your training as similar to race day as possible, try doing two-legged or single-legged squats while waiting for the elevator and while in the elevator.  And consider adding in heel raises between squats as well as moments of single arm support on the elevator handrail.  

Although it may feel awkward with other residents around, the benefits of these drills will pay off.


As a note, if you are doing speed repeats and require a breather in-between climbs, skip the squats.  In this instance, you are doing an anaerobic, fast-twitch based workout and taking a break between climbs will be important.  

Otherwise, take advantage of these elevator drills to give yourself an extra edge in your training!

​Encouragement - both for yourself and your fellow climbers

Encourage others as you pass them or as you get passed - focusing on other climbers’ success will keep your mind off the muscle fatigue and pain and help keep you charging up the tower!  Remember, this competition is for a good cause - please make it as positive and enjoyable as possible for all participants.

Biomechanics for a left rotational climb - like the Columbia Tower stairwell

Consistently turning to the left at the top of each stairwell and to progress to the first stair of the next flight means you need a lot of hip mobility and strength in certain areas.  Although your body needs to use and control all 3-planes of motion at every joint, there are some extreme ranges the body will go through during a stair climb that involves a stairwell with a left rotated climb.  

Let’s consider the feet and hips together.  As a note, each of the biomechanics scenarios discussed in this section have to do with the left rotation required while stepping onto a landing between flights of stairs and then up to the first or second step of the next flight of stairs
Picture
Stepping onto the left foot at a stairwell landing

When you step onto your left foot on the landing between flights of stairs and you are already preparing to turn left to go up the next flight, your left foot will turn out relative to your knee - the result is an externally rotated foot which, when coupled with forward momentum of the left knee, will require and should generate a huge amount of subtalar joint eversion and forefoot inversion.  
-- Food for thought: can your left foot successfully use and control a large amount of pronation? ---

The left hip will be externally rotating until your foot hits the ground when it will internally rotate a small amount because of your left foot’s pronation.  Your left hip needs to be able to decelerate hip flexion + internal rotation + adduction.  If it cannot, it is likely your knee will collapse to the inside at every landing.  The result is excessive lateral knee joint compression and medial knee gapping (excessive lateral meniscus pressure, excessive medial collateral stretch, excessive lateral pull of the patella).
-- Food for thought: can your left hip successfully use and control flexion + internal rotation + adduction? --

Picture
Stepping through the left foot at a stairwell landing

The left foot also needs a lot of supination - when your left foot is planted on a landing between flights of stairs and your right foot is swinging up to the next stair, your left foot is internally rotated relative to your knee and your subtalar joint should be inverting while the forefoot everts to help keep your big toe down on the floor so you have a solid point to push from to carry your momentum forward and up.
-- Food for thought: can your left foot supinate successfully so you have a solid lever from which to push your body up to the next stair and onto your right foot? --

The left hip will require a huge amount of internal rotation + abduction + extension in order for you to step forward and onto the next stair and onto your right foot.  
-- Food for thought: does your left hip have the ability to use and control internal rotation + abduction + extension when stepping forward onto your right foot to get up to the next stair? --

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Stepping onto the right foot at a stairwell landing

When you first step onto the landing with your right foot, the foot is internally rotated which has a tendency to make it harder to pronate.  We need foot pronation to dampen impact forces and to allow the glute muscles to activate.  
-- Food for thought: can your right foot still pronate when your foot is internally rotated? --

The right hip may or may not experience internal rotation during the loading phase of stepping onto your right foot - this is because of relative rotation.  Depending on the rate at which your pelvis rotates left while your femur rotates left will determine if your glutes are going to get stretch at all via internal rotation.  However, we do know that your right hip will need a lot of flexion and adduction. 
-- Food for thought: can your right hip use and control flexion + adduction? --

Picture
Stepping through the right foot at a stairwell landing

As you swing your left foot through while standing on your right leg, your right foot will be externally rotating making it harder for your foot to successfully supinate (your subtalar joint will want to evert rather than invert).  As a result, your calf will need to work extremely hard to help control what your heel does in space.
-- Food for thought: can your right foot supinate despite your entire body rotating to the left and can you still push off from your big toe successfully? --

Your right hip will be externally rotating, abducting, and extending.  If you have tight abductors, a history of a right hip labral tear, or simply a locked up or weak right hip, it will be a challenge to achieve those 3-dimensional mechanics.
-- Food for thought: can your right hip use and control external rotation + abduction + extension? --

There is a lot more that should be considered when it comes to the biomechanics of a stair climb, such as: biomechanics of the hips and feet while climbing directly up the stairs (no global left rotation) and biomechanics of the thoracic spine and shoulders while using the railings in a variety of positions (opposite handrails or same handrails or no handrails).  ​​


My training plan

Sunday: alpine and/or nordic ski
Monday: run and functional workout
Tuesday: rest day 
Wednesday: stair training day and functional workout
Thursday: run and functional workout
Friday: rest day
Saturday: alpine and/or nordic ski

​Professional injury and biomechanics assistance

If you need a biomechanics analysis or are experiencing pain while climbing stairs, let one of our expert physical therapists help you move and feel better!  Call us at (206) 279-2870 or email at hello@forefrontpllc.com.  You can also request an appointment online via this link.

​Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy
Belltown & South Lake Union
2720 4th Ave Ste 115
Seattle, WA 98121

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1/14/2018

How to Crush the Columbia Tower Stair Climb: Functional Stair Drills (Part II)

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Make stairs fun and easy with 3-dimensional training!

By: Dr. Dan Benson, DPT, OCS, FAFS
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Now, it’s time to play on the stairs!  But be careful!  After you master your foundational stair exercises from the Part I blog post, you will be ready to slowly start incorporating some of the stair drills included in the videos below.  

We filmed a functional series of warm ups and various ascent and descent drills to 3-dimensionally mobilize and strengthen your legs.  Because walking up stairs creates up to 6x our body weight in contact forces within the knee joint, it is essential that both strength and control are trained as optimally as possible. 

It is likely that ascending stairs at a faster rate results in even more forces within the knee joint.  As such, make sure you vary your stair training so the force application within the knee changes often and so that you can target more muscles in your legs.  Additionally, reach out to one of our biomechanics experts to make sure your knee is being properly supported during stair climbing by its most important friends: the foot, hip, and thoracic spine.   

Next week's final stair climbing post will include stairwell specific drills and strategies to help you achieve your personal best climb time.

As always, make sure you chat with your physical therapist before trying any of our drills!







If you would like to support my participation and/or my team’s participation in the Big Climb, please visit: http://www.llswa.org/site/TR/Events/BigClimb?px=1693676&pg=personal&fr_id=1580 to donate.  Also, if you would like to train with the SGLRG Stair Crushers, feel free to join the group that Mo created on Facebook so that you can stay in the loop with stair workout meetups.  Training with this group is a positive, encouraging experience and can be helpful for anyone who wants to change up their fitness routine and develop some healthy leg strength and cardio fitness. 

Reference:
- ​https://www.ncbi.nlm.nih.gov/pubmed/12127184

​Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy
Belltown & South Lake Union
2720 4th Ave Ste 115
Seattle, WA 98121

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1/8/2018

How to Crush the Columbia Tower Stair Climb - Mobility & Stability Training (Part I)

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Make stairs easier by developing a functional foundation

By Dr. Dan Benson, DPT, OCS, FAFS
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I cannot believe Mo convinced me, and many other members of the Seattle Green Lake Running Group (SGLRG) Stair Crushers, to sign up for another stair climb at the Columbia Tower.  Every year, the Leukemia & Lymphoma Society hosts the Big Climb Seattle at the Columbia Tower.  It is an incredible event which raised almost $3 million dollars last year!  

It is also a brutal event - especially if you choose to time yourself and turn the 1,311 stairs over 69 flights into a race.  By the time you reach the top, you can hardly breathe or walk.  If you have ever experienced “track hack”, it is not fun and is almost guaranteed to occur to each individual when they reach the top of the climb.  

But the race is an adrenaline rush.  There are few races that can so completely test your limits in such a short period of time while serving as an opportunity to support a wonderful cause - this makes the event hard to pass up.    

With the climb being less than 3 months away, it is my goal to help my stair climb team and all participants experience more success at the event - this means faster climbing times with less likelihood of injury.  As a physical therapist specializing in biomechanics and someone who was fortunate enough to finish in the top 4 of the climb last year, I have a unique ability to offer special insights into stair climb training and racing.  Although the SGLRG Stair Crushers group is participating in the Big Climb for altruistic reasons, we would like to do our best and win as a team.  

As such, the mobility and stability drills offered below are designed with performance in mind.  If your goal is to be a top finisher and train safely and effectively, consider trying the exercises in this post.  As a note, my next post will offer functional stair ascent and descent drills while the final post will be all about strategy when training specifically in a stairwell and how to prepare for the subtleties of the Big Climb.

I hope you enjoy the foundational moves filmed for this blog post series.





If you would like to support my participation and/or my team’s participation in the Big Climb, please visit: http://www.llswa.org/site/TR/Events/BigClimb?px=1693676&pg=personal&fr_id=1580 to donate.  Also, if you would like to train with the SGLRG Stair Crushers, feel free to join the group that Mo created on Facebook so that you can stay in the loop with stair workout meetups.  Training with this group is a positive, encouraging experience and can be helpful for anyone who wants to change up their fitness routine and develop some healthy leg strength and cardio fitness. ​

Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy
Belltown & South Lake Union
2720 4th Ave Ste 115
Seattle, WA 98121

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12/18/2017

Six Ways to Improve Your Running Performance This Offseason - Part VI: Running Related Strength Training

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Running Specific Strength Training Is Essential To Any Runner’s Weekly Training


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You may be intimately familiar with every tree root and concrete bump as you make your way around the 3-mile Green Lake loop, but are you familiar with 3-dimensional split squats? Or a single leg Romanian Deadlift? How about multi-angle pistol squats?  Running is incredibly effective at training cardiovascular endurance, however, strength training is often neglected by runners and should be a key component to their fitness.  

Why Is Strength Training Essential For Runners?
When compared to walking, running increases ground reaction forces around three times one’s body weight per step.  This means that someone weighing 120 pounds may have up to 360 pounds of force bearing down on a single leg while running. Multiply that by the thousands of steps taken per run and it is now easy to realize that the biomechanical load going through the body is huge!  

Muscle and connective tissue need to be adequately strong to successfully bear such intense repetitive forces. Strength training places greater than normal stress through these tissues which results in physiological adaptation and increased strength - exactly what runners need to safely tolerate the forces inherent to running.

What Kind of Strength Training is Running Specific?
A program to load the body in running specific positions will help increase speed, endurance, muscle, and connective tissue strength. Plus, it decreases the likelihood of running related injury!  

A running strength training program should focus on the specific needs of runners including, but not limited to, the notoriously weak posterior chain (glutes and hamstrings). An effective program should also consist of compound, multi-joint movements (eg. squats and deadlifts) and not the knee extension machine at the gym!

Since running involves alternating single leg support, strength training should include single leg drills. Additionally, strength moves must be done 3-dimensionally.


Will Strength Training Increase My Body Weight?
One of the most common misconceptions is that runners who perform strength training will end up with too much muscle hypertrophy, or increased muscle mass, and thus, increased body weight.   

At the physiological level, running is a catabolic form of exercise (muscle breaks down), whereas weightlifting is typically anabolic (muscle is created). A proper balance of catabolic (running) and anabolic (strength training) exercise will lead to the creation of lean, healthy muscle mass. This physiological opposition will make strength training unlikely to increase body weight.  Weight gain may occur if caloric intake is increased drastically or the running regimen is reduced, thereby creating a situation in which anabolic exercise is greater than catabolic.

Does CrossFit Count As Strength Training for Runners?
CrossFit could be a good strength training supplement, but there are caveats.  Although some CrossFit movements are helpful for runners, it does not effectively address the specific needs of runners.  Plus, many movements require a lot of practice in order to be performed safely.  Some lifts may be too advanced for novices and often lead to injury due to compensatory patterns.

I recommend CrossFit only for runners who have already been participating in classes and feel comfortable with all movements.  And for those who are comfortable with CrossFit workouts, I still recommend they integrate more functional, running specific exercise.

For new runners or those just beginning to explore a strength training regimen, I recommend they initially refrain from CrossFit, and instead perfect less advanced movements like squatting, lunging, and deadlifting.  

The risk for injury in CrossFit without proper mobility, stability, and technique training first is not worth the potential gains in strength.  Additionally, 3-dimensional, running specific exercise must be incorporated in a runners strength program regardless of CrossFit workouts.

How Often Should I Strength Train?
A strength program should be utilized once per week, at the minimum, and up to three times per week at the maximum.  To maximize the benefits of strength training, I recommend strength training on “easy run days” to help prevent injury and compensatory movements.  

Do I Need a Gym Membership to Do Strength Training?
​Definitely not! Strength training can be completed with little to no equipment.  However, adding resistance (barbells, dumbbells, kettlebells, cable pulleys) will make it easier to increase strength gains.

What Lifts Should I Be Doing?
As mentioned above, running specific strength training should mimic the natural gait cycle. Movements like single leg deadlifts, single leg squats, and lunges can be tailored for running specific training.   Endurance athletes should be able to do 3-5 sets of 16-24 repetitions of each movement/lift they are completing.  

Still unsure about what lifts to do and how to program strength training for runners?  Forefront offers a personalized, step-by-step guide for strength training.  After going through our functional mobility and strength examination, we will create a program specific to your needs and goals.  Contact bwhitley@forefrontpllc.com for more information.

3-Dimensional Lunge Matrix + Speed Skater Single Leg Squats with "Running Arms"


3-Dimensional Single Leg Squats with "Running Arms"
(progressions included)


3-Angulation Romanian Deadlifts with "Running Arms"


Single Leg Stability Squats with "Running Arms"


Core Strength with Running Tweaks


Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy
Belltown & South Lake Union
2720 4th Ave Ste 115
Seattle, WA 98121

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11/30/2017

Six Ways to Improve Your Running Performance This Offseason - Part V: Running Related Agility

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Agility Training Increases Your Durability & Enhances Your Running Performance

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On the macroscopic level, running is predominantly a one-dimensional exercise.  When looking at each joint, however, you will find three dimensional movement.  Because of this multidimensional movement, runners of all levels should use training that incorporates all three planes of motion. An agility program is a great way to integrate non-linear movement into any running routine.  Among other things, agility training challenges vision, dynamic balance, coordination, strength, power, and acceleration/deceleration capabilities. For this reason, it is a great supplementary workout for runners.

Agility training has been shown to improve more than just athletic prowess.  A military study looked at how an agility program affected the participant’s endurance, athletic tests, and cognitive function.   The group performing agility training improved their VO2 Max, athletic footwork, memory, and concentration.  It is theorized that agility training takes advantage of the principle of neuroplasticity, or the brain’s ability to change its connections and behavior in response to new information and sensory stimulation.  

Consider picking up an agility ladder on Amazon for $13, or build your own for less than $5.  Ideally, an agility program will address all three planes of human movement: sagittal (forward and backward), frontal (side-to-side), and transverse (rotations parallel to the ground).  

Want to incorporate agility but not interested in agility ladder training?  Consider trying trail running first. This form of running requires greater balance and agility as compared to road or track running, so it could be an alternative or supplement to a more structured program.  

Below are my go-to agility drills split into the three different planes of movement. While it may be hard to break a strict running routine, supplementing footwork and agility drills 1-2 times per week might just be enough to break that recent plateau and set a new personal record.  Just be careful, agility training, like faster running, creates dramatically more force than your body may typically be used to controlling. So take it easy the first few times you attempt any agility training, and consider meeting with a member of our team at Forefront to develop your ideal, individualized program.

Sagittal Plane Agility

Frontal Plane Agility

Transverse Plane Agility

Single Leg Agility/Stability
Begin with 2 Rounds x 5 Reach/Jumps per side. Progress as you are able to complete all 10 while maintaining proper form and completed without re-setting.

References: 
Lennemann LM, Sidrow KM, Johnson EM, Harrison CR, Vojta CN, Walker TB. The influence of agility training on physiological and cognitive performance. J Strength Cond Res. 2013;27(12):3300-9.
Cissik, J. & Barnes M. Agility (Chapter 5). Sport Speed And Agility. Coaches Choice. Monterey CA, 2004



Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy

Belltown & South Lake Union
2720 4th Ave #115
Seattle, WA 98121

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11/14/2017

Six Ways to Improve Your Running Performance This Offseason - Part IV: Running Biomechanics

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​Changing Running Mechanics Could Help Decrease Your Knee Pain

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It is no secret that distance running places a significant demand on the body’s musculoskeletal system. The cyclic impact (ground reaction) forces inherent to running continuously load the lower extremity and spine with every step. Due to this constant, repetitive stress, overuse injuries are common and can likely be attributed to less than optimal biomechanics.  

Although the running cycle is complex, we discuss three of the most well known and researched components (foot strike, trunk position, step rate / stride length). Additionally, we will provide a few examples of how altering your running biomechanics may help decrease pain and improve performance.


Foot Strike
The manner in which the foot initially contacts the ground has been classified into three popular subgroups: forefoot, midfoot, and heel strike. A majority of distance runners likely fall into the heel strike category, however, elite performers are less likely to heel strike.  

Elite runners who heel strike do so
with their foot directly under their body while non-elite runners tend to heel strike out in front of their body - this blocks forward momentum which results in a massive increase in ground reaction forces and an increased likelihood of injury.  It does not mean that these runners need to change to a different foot strike, they may just need to address biomechanical issues to improve how they are heel striking.

As a note, research struggles to clearly identify any economical or performance benefit in distance runners when it comes to midfoot or forefoot striking.  As speed increases, most runners do, however, tend to naturally shift toward a midfoot or forefoot running pattern.


My recommendation:  When necessary, intentionally changing footstrike may be an option to reduce stress on various tissues.  For example, heel striking increases impact forces at the knee compared to midfoot striking.  Thus, people with chronic knee could pain try a midfoot strike.

Conversely, midfoot and forefoot striking is associated with a greater load on the Achilles tendon, so people with chronic Achilles or calf pain may be advised to use a heel strike. Although changing to a rearfoot strike pattern may reduce the likelihood of Achilles related issues, foot and hip biomechanics are most likely the culprit of the Achilles pain.


Forward Trunk Lean
Running methods like ‘ChiRunning’ and POSE method promote a forward lean of the trunk while running.  The biomechanical reasoning behind a forward lean is that it better incorporates the power of the posterior chain.  

Research on this topic is mixed.  A recent study concluded that runners who implemented a forward trunk lean as well as an increased  step rate (see below) 
reduced their risk of knee injury.  On the other hand, another study
 concluded that using the POSE method of running for three months actually worsened the triathlete’s running economy compared to their habitual running form. 

Due to the mixed results of research thus far, ChiRunning and POSE method should be trialed with caution.  Unfortunately, none of these studies account for biomechanics issues, such as mobility and stability throughout each participant's body, which makes it challenging to draw conclusions.  Any restriction in posterior chain mobility may result in an inability to successfully implement a forward lean.

As a note, it is essential that runners do not fall into the habit of overly tightening their core when trialing these ChiRunning and POSE running methods as this can actually block the ability of the torso to counter rotate relative to the hips thereby shutting down the efficiency and activation of the core and glutes.  


My Recommendation:  If you are a runner suffering from knee pain, you may want to consider an increased forward trunk lean complemented with an increased step rate.  To implement this technique, subtly lean forward bending at the ankles, forming a straight line from ankles to shoulders.  Research shows that about 14 degrees of forward lean can be enough to decrease impact at the knee. 

Spatiotemporal (Step Rate and Stride Length)
Running speed is a function of step rate and stride length.   Step rate is measured in steps per minute and stride length is measured in distance from toe off to foot strike.  By increasing one or the other (or both), running velocity increases directly.   

A decreased step rate (fewer steps per minute) is associated with a greater likelihood of shin and knee injury while an increased step rate coincides with decreased stride length, decreasing the likelihood of running injury.  Modifying these two running characteristics is  a direct strategy to reduce the likelihood of running injury.  


My recommendation:  If you are injured, consider modifying your running form by changing your step rate and stride length.   A subtle 5-10% increase in your step rate has been shown to reduce ground reaction and joint forces during running. iPhone and Android apps like AudioStep, Running Cadence Tracker, and RunCadence,  can aid in helping you adjust your step rate.

No Right Way To Run
It is important to remember that no one running style or body type wins all races, even at the most elite levels.  All runners have individual physical, biomechanical, emotional, and physiological strengths and weaknesses.  Thus, a change that works for one runner, may not work for another. It is most important to find and develop your own style of running.  Your goal should be to optimize your body’s abilities and address your biomechanical related issues so you can run at your best and without pain.

Be aware that changing running biomechanics may cause an unexpected injury, so don’t change too many things too quickly or too intensely!  If you cannot seem to solve your running aches and pains with these quick biomechanical changes, there is likely an underlying problem that needs to be addressed with an in-depth biomechanical examination by your physical therapist.

References:
Kasmer, M. E., Xue-Cheng, L., Roberts, K. G., & Valadao, J. M. (2013). Foot-Strike Pattern and Performance in a Marathon. International Journal Of Sports Physiology & Performance, 8(3), 286.

Warr, B. J., Fellin, R. E., Sauer, S. G., Goss, D. L., Frykman, P. N., & Seay, J. F. (2015). Characterization of Foot-Strike Patterns: Lack of an Association With Injuries or Performance in Soldiers. Military Medicine, 180(7), 830-834. doi:10.7205/MILMED-D-14-00220.

Dallam GM, Wilber RL, Jadelis K, Fletcher G, Romanov N. Effect of a global alteration of running technique on kinematics and economy. J Sports Sci. 2005;23(7):757-64.

Teng HL, Powers CM. Sagittal plane trunk posture influences patellofemoral joint stress during running. J Orthop Sports Phys Ther. 2014;44(10):785-92.
​

Luedke LE, Heiderscheit BC, Williams DS, Rauh MJ. Influence of Step Rate on Shin Injury and Anterior Knee Pain in High School Runners. Med Sci Sports Exerc. 2016;48(7):1244-50.

Dr. Brad Whitley, DPT
Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy

Belltown & South Lake Union
2720 4th Ave #115
Seattle, WA 98121

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11/13/2017

Six Ways to Improve Your Running Performance This Offseason - Part III: Anterior Chain and Chest Mobility

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The Posterior Chain May Get All The Glamour, But Don't Neglect Anterior Chain Mobility 

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Like the posterior chain, muscles of the anterior chain (Hip Flexors, Quadriceps, Abdominals, and Pectorals) may have limited flexibility due to a multitude of causes.  Insufficient stretching, improper running biomechanics, or poor sitting postures may lead to decreased anterior chain mobility.   When the anterior chain muscles are tight, motion will occur at other places where it may be a detriment to the athlete. In this blog post, we explore how the anterior chain may contribute to less than optimal running performance as well as knee, hip, low back, and even neck pain and how exercise may be used to improve performance and alleviate pain.

Hip Flexors & Quadriceps
Running places a significant demand on the hip flexors and quadriceps (quads).   As the foot prepares to push off the ground, the hip flexors and quads become stretched through hip extension, internal rotation, and abduction which allows for a rapid elastic recoil effect - the energy created by this stretch is what drives the knee forward during swing phase to successfully set the leg up for the next foot strike. Tight hip flexors and quads limit hip extension which is one of the most common causes of low back pain with running (and walking too).  Limited hip extension may also contribute to knee pain, overuse calf injuries, and IT Band Syndrome.  

Improve Hip Extension (Hip Flexor & Quad Stretch)
Try this stretch by starting in a kneeling position with one knee down (back foot can be elevated against a box or wall as shown below) and the other foot planted on the ground in front.  From this base position, tuck the pelvis under by contracting the abdominals and glutes.  At this point you will likely feel a stretch along the front of the thigh. Maintain this tucked position and slowly swing the arms through all three planes of motion to drive a 3-dimensional hip flexor and quad stretch.

Pectoralis Minor and Major (Pec)
Just as suboptimal hip flexor and quad length limits full extension of the hip, limited pectoral mobility prevents full chest expansion (a fundamental component of aerobic exercise) and thoracic spine rotation (a fundamental component of core engagement).  Tight pecs result in forward, rounded shoulders and may be accompanied by forward head posture which places more stress on the neck.  These are classic postural problems caused by sitting but can be addressed through functional mobility and stretching drills.
​

Improve Pec Flexibility
Start by placing your hand on wall or door frame - your hand should be placed high enough that your elbow is above shoulder height.  Gently push your chest forward, past the elbow and hand until a stretch is felt through the front of the chest.  If you are stretching your left pec, your left hand should be elevated on the wall and your left foot should be forward.  Pulse the chest forward (1 inch or less) to achieve a more dynamic stretch. Try repeating the stretch but use rotational pulses this time.  Be careful to lead with the chest and not with the shoulder itself, as this may cause shoulder discomfort.  Please make sure you adequately squeeze your shoulder blade down and back so that you keep the front of your shoulder (anterior shoulder capsule) safe.

Rib Mobility
Although not limited just to the anterior chain, rib mobility is an essential part of a runner's overall performance.  Like pectoral flexibility, rib mobility is essential for optimal breathing.  The ribs need to rotate and translate 3-dimensionally during breathing, and with poor rib mobility, cardiovascular performance may be compromised.  Improving rib mobility will likely coincide with improving thoracic spine mobility as the two are intricately related.

​
Improve Rib and Thoracic Spine Mobility
While doing small forward lunges, move the arms in the patterns listed below:
  • Right Leg Forward: right arm reaches overhead to the left, left arm rotates across the body to the right
  • Left Leg Forward: right arm reaches overhead to the left, left arm rotates across the body to the right
*Inhale deeply while moving into the rotation, and exhale while returning to the starting position

​These exercises are meant to improve hypomobility through areas that are vital to running biomechanics and performance.   Completing these exercises intentionally and consistently will improve the way you move and make you more efficient with your running or sport performance.

Dr. Dan Benson, DPT, OCS, FAFS

Forefront Physical Therapy

Belltown & South Lake Union
2720 4th Ave #115
Seattle, WA 98121

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