Clinical Aspects of Running Gait
Analysis
Amanda Gallow and Bryan Heiderscheit
Introduction
An increased desire for a healthy lifestyle and
awareness of the multiple health benefits associ-
ated with running has resulted in a sustained popu-
larity for the activity in the United States and other
countries. From 2002 to 2015, the number of indi-
viduals finishing running events increased 300 %
to nearly 20,000,000 race finishers each year [1].
The annual rate of running-related injuries ranges
from 24 to 65 %, with the most commonly injured
joint being the knee [2, 3]. Among runners train-
ing for a marathon, the injury rate has been
reported as high as 90 % [3]. Novice runners,
defined as individuals with little to no running
experience, comprise a growing portion of runners
and may be at greatest risk. For example, novice
runners (17.8 injuries per 1000 h of running) are
more than twice as likely than recreational runners
(7.7 injuries per 1000 h) to sustain a lower extrem-
ity musculoskeletal injury [4].
A. Gallow
Sports Rehabilitation Clinic, UW Health
at The American Center, 4602 Eastpark Blvd,
Madison, WI 53718, USA
B. Heiderscheit (*)
Departments of Orthopedics and Rehabilitation and
Biomedical Engineering, UW Runners’ Clinic,
Badger Athletic Performance Research, University of
Wisconsin-Madison, 1300 University Ave., Madison,
WI 53706, USA
e-mail: heiderscheit@ortho.wisc.edu
© Springer International Publishing Switzerland 2016
T.L. Miller (ed.), Endurance Sports Medicine, DOI 10.1007/978-3-319-32982-6_15
15
A variety of specific factors have been associ-
ated with an increased risk for a running-related
injury including previous running injury, age,
gender, mileage per week, BMI, and shoe age [2,
3, 5, 6]. However, injuries can generally occur
secondary to four main factors: musculoskeletal
impairment [7], extrinsic causes such as running
surface or shoes [8], training error [9], and faulty
running mechanics [10, 11]. Traditionally, man-
agement of running injuries has emphasized fac-
tors that are easily assessed by taking a thorough
history or performing a complete physical exami-
nation. However, as measurement technology has
improved, our ability to capture running mechan-
ics as part of a routine clinical exam has increased,
as well as our ability to integrate this information
into our clinical decision-making process.
In this chapter, we will describe a standard-
ized approach to assess running mechanics
using high-speed video analysis. While recog-
nizing that many options exist regarding equip-
ment and procedure, it is our intent to provide
the reader with a framework of the essential
elements needed to conduct a video assessment
of a runner as it relates to injury recovery and
prevention.
Getting Started
Clinical video analysis of running enables the
clinician to characterize the patient’s running
biomechanics, estimate the resulting joint and
201
202
muscle loads, and identify aspects that may be
associated with injury risk. However, this infor-
mation is of limited value in isolation and there-
fore should always be combined with a thorough
history and physical examination. In doing so,
the relationship between individual physical
impairments and altered running mechanics is
better understood, especially as it relates to the
individual’s injury. The information gathered can
then be utilized to develop the patient’s plan of
care and route of treatment.
Computerized three-dimensional (3-D)
motion capture is considered the gold standard
for movement analysis, providing the most accu-
rate and comprehensive means to assess running
mechanics. However, most clinics lack the neces-
sary equipment or personnel for this approach,
thereby limiting its use in general practice. As
such, more feasible alternatives have been sought;
likely the most commonly used approach is
observational video analysis.
In its simplest form, observational video analy-
sis typically involves the use of a video camera to
record the runner’s mechanics during either tread-
mill or overground running. Two-dimensional
(2-D) views from the frontal and sagittal planes
are typically obtained; multiple cameras may be
used to provide a synchronized recording across
planes of interest. The recordings are then played
back directly to a monitor or through video analy-
sis software and reviewed with regard to norma-
tive biomechanical values and to the amount of
side-to-side asymmetry.
Comparisons between 2-D and 3-D analyses
of running mechanics have been limited to fron-
tal plane motions of the rearfoot [12] and hip
[13], with both demonstrating comparable values
when a strict measurement procedure is followed.
It is important for the clinician to remember that
there are distinct limitations with a 2-D analysis
that will prevent the measurement accuracy and
precision possible with a 3-D approach. As a
result, the interpretation of the 2-D video must be
made with this in mind.
To maximize measurement accuracy and reli-
ability of a clinical video analysis, several factors
must be considered. First, observational video
A. Gallow and B. Heiderscheit
analysis can have questionable reliability.
Utilizing a consistent and systematic approach to
the video analysis and developing experience in
conducting video analysis will increase examiner
reliability [14]. Second, to accurately identify
specific events of the gait cycle (e.g., initial con-
tact, mid stance), a camera with sufficient frame
rate is necessary. Most commonly available video
cameras record at 30 or 60 frames per second
(fps). Although adequate for walking, these
frame rates are insufficient for faster motions
such as running where 100–120 fps is needed to
more accurately capture the motions of the lower
extremity, especially those which occur during
foot-ground contact. Finally, placement of the
tripod-mounted video camera needs to be per-
pendicular to the plane of interest. This is con-
cerning for frontal plane measures, where
out-of-plane motion can be substantial relative to
that occurring within plane [15]. Unless a ceiling-
mounted camera is available, motions occurring
in the transverse plane are least accurate as they
are inferred from the frontal and sagittal plane
views.
The presence of these limitations should not
prevent one from utilizing observational video
analysis. Instead, knowledge of the limitations
should enable one to avoid potential errors, such
as trying to quantify rather subtle motions or
interpreting minor changes (<5°) as real. While a
variety of video analysis software is available and
makes such measures seemingly possible, the
software cannot overcome the inherent limita-
tions of a 2-D video capture.
Patient Setup and Video Capture
The choice between analyzing running mechan-
ics on a treadmill and overground is often deter-
mined based on practicality and feasibility. For
example, treadmill analysis requires much less
physical space than overground and can often-
times be the determining factor. Performing an
overground analysis offers greater ecological
validity; that is, most runners run most of their
miles overground and not on a treadmill, making
15 Clinical Aspects of Running Gait Analysis
overground running the more natural setting.
This is an important consideration, as the analy-
sis needs to capture the runner’s typical running
mechanics to determine if they may be contribut-
ing to injury. However, overground running pres-
ents with its own set of challenges that can
increase measurement error including monitor-
ing and maintenance of a constant running speed,
perspective and parallax errors as the runner
moves in and out of the field of view, and ability
to record a limited number of gait cycles to repre-
sent the runner’s typical mechanics. While the
use of a treadmill can address all of these issues,
additional factors need to be considered such as
the runner being comfortable on a treadmill, suf-
ficient stiffness of the treadmill deck to mimic
overground running, and adequate motor power
to ensure a constant speed of the treadmill belt.
Although it is often assumed that biomechanics
are dramatically different when running on a
treadmill compared to overground, if the prior list
of factors is addressed, the differences are gener-
ally minor [16].
The patient should wear contrasting colors
with the shirt tucked into the level of the poste-
rior superior iliac spines (PSIS) to improve the
identification of pelvic alignment. If the patient
is comfortable running without a shirt, then he or
she should be encouraged to do so as it further
improves the visual assessment of trunk and pel-
vis motion. Because runners are generally more
comfortable running overground, treadmill
familiarization is important and may involve
walking for a couple of minutes prior to running.
The treadmill should be set to a 0° incline (level),
unless uphill or downhill running is of particular
interest. It is recommended that the patient be
allowed to run for at least 5 min at a self-selected
speed before video recording begins to allow for
the running form to normalize [17]. The patient’s
choice of running speed should reflect the condi-
tions in which the symptoms are provoked and
may include easy, moderate, or racing speeds.
Depending on the chosen speed, only 10–15 s of
recording from each movement plane is typi-
cally needed to obtain well over 20 strides for
each limb.
203
Analysis of the Recorded Video
Understanding the running gait cycle is impera-
tive for proper clinical gait analysis and commu-
nication with runners. The running gait cycle can
be broken down into loading response (initial
contact to mid stance), push-off, and swing
(Table 15.1). The factor that distinguishes run-
ning from walking is the period of double float
when both feet are off the ground. Important tem-
poral spatial gait parameters that assist with clini-
cal gait analysis are listed in Table 15.2.
While preparing the patient and capturing the
video can quickly become a simple, routine aspect
of performing a clinical running gait analysis,
learning to break down the video and identify spe-
cific mechanics associated with injury is generally
more complicated. The specific approach to
reviewing and interpreting the video can widely
vary; however, several basic parameters are worth
noting to characterize the running mechanics.
These will assist in determining biomechanical
faults and imbalances that may be contributing to
the runner’s dysfunction and provide insights into
the ground reaction force and joint loading. Please
note that all values provided are estimates and
reflect running at preferred, comfortable speed.
Sagittal Plane
Sagittal plane body postures have been found to
estimate ground reaction forces and joint kinetics
[18]. This is important to understand when work-
ing with runners because a common risk factor for
running-related injuries is increased joint loads and
ground reaction forces [19]. It’s helpful to develop
a systematic top-down or bottom-up approach to
analyze the sagittal plane with particular attention
paid to initial contact and mid stance.
Initial Contact
Initial contact, the instant at which the foot first
makes contact with the running surface, can be
clearly identified in the sagittal plane allowing
204 A. Gallow and B. Heiderscheit

Table 15.1 Events within the running cycle

Definition
Initial contact Instant at which the foot first makes
contact with the ground and is best
identified in the sagittal plane

Mid stance Instant when the body’s center of mass

Frontal plane Sagittal plane (COM) is directly over the foot and at its
lowest vertical position of the gait cycle.
This can be identified both in the frontal
and sagittal planes

(continued)
15 Clinical Aspects of Running Gait Analysis
Table 15.1 (continued)
Mid-float
Table 15.2 Temporal spatial gait parameters
Definition
Stride Time between successive initial
duration (s) contacts of the same foot
Step Time between initial contact of one
duration (s) foot to initial contact of the other foot
Stride Distance from initial contact of one
length (m) foot to the same foot
Step Distance from initial contact of one
length (m) foot to initial contact of the other foot
Speed (m/s) Distance traveled per unit of time. Can
be calculated as stride length divided
by stride time
Cadence Number of steps within a minute of
(steps/min) running
for the assessment of the lower extremity posture.
This posture at initial contact is associated with
the resulting ground reaction forces and loads to
the lower extremity joints and muscles [18]. The
following kinematic parameters are of particular
importance: foot inclination angle, foot to center
of mass (COM) horizontal distance, leg inclina-
tion angle, and knee flexion angle.
Foot Inclination Angle The foot inclination
angle is the angle between the running surface
205
Definition
Midpoint between toe off of one foot and
initial contact of the other, corresponding
to the instant when the body’s COM is at
the highest vertical position
and the sole of the runner’s shoe and allows for
the determination of foot-strike pattern
(Fig. 15.1). A heel-strike pattern occurs when the
runner lands on the posterior aspect of their heel
and is evident by a more steep foot inclination
angle. A rearfoot-strike pattern involves the run-
ner landing more on the anterior aspect of the
heel, generally with a foot inclination angle of
10° or less. A mid foot strike is characterized by
both the rearfoot and forefoot making contact
nearly simultaneously, with a foot inclination
angle near 0°. A forefoot-strike pattern occurs
when a runner makes initial contact on the fore-
foot resulting in a negative foot inclination angle.
As foot inclination angle increases, so does peak
vertical ground reaction force, braking impulse,
knee extensor moment, and negative work per-
formed by the knee extensors, all of which have
been associated with various running-related
injuries [18]. A large proportion of runners are
unable to accurately determine their foot-strike
pattern by simply asking them [20], requiring the
clinician to directly assess this in clinic.
Horizontal Distance from Foot to COM The
horizontal distance from a runner’s foot placement
206 A. Gallow and B. Heiderscheit

Fig. 15.2 Horizontal distance from the foot to body’s

Fig. 15.1 Foot inclination angle is the angle between the
center of mass (COM) is measured at initial contact from
running surface and the sole of the runner’s shoe and
the point of foot-ground contact to the body’s line of grav-
allows for the determination of foot-strike pattern
ity, estimated as the center of the pelvis

at initial contact to the whole body’s COM (esti-

mated at S2) will influence the resulting ground
reaction forces (Fig. 15.2). Specifically, a greater
distance between the foot’s point of contact and
the COM increases the braking impulse and
resulting knee extensor moment during the load-
ing response [18].

Leg Inclination Angle The leg inclination

angle is the angle of the midline of the leg in
relationship to true vertical (Fig. 15.3). This
angle can play a role in the amount of loading
that occurs to the tibia during running. Increased
instantaneous and average vertical loading rates
and tibial peak accelerations were found in run-
ners with a history of tibial stress fracture [11].
The leg inclination angle is altered with a
reduction in stride length to a more vertical
position. Specifically, a reduction in tibial con-
tact force while running was observed when
stride length was reduced by 10 %, which may
have implications for preventing tibial stress Fig. 15.3 Leg inclination angle is the angle between the
injuries [21]. midline of the leg and true vertical
15 Clinical Aspects of Running Gait Analysis
Fig. 15.4 Knee flexion angle at initial contact is mea-
sured between the midline of the thigh and the midline of
the leg
Knee Flexion Angle Knee flexion angle at ini-
tial contact is measured as the angle between the
midline of the thigh and the midline of the leg
(Fig. 15.4). A more extended knee is commonly
observed in individuals who overstride and have
an aggressive heel-strike pattern. Knee flexion
angles near 20° are generally recommended.
The combination of these measures deter-
mines whether an individual is overstriding. For
example, a lower extremity posture at initial con-
tact comprised of decreased knee flexion angle,
increased leg inclination angle, increased
horizontal distance from heel to COM, and
increased foot inclination angle is reflective of an
overstriding pattern and is associated with
increased ground reaction forces and loading to
the hip and knee joints [22].
Mid Stance
Two joint alignment measures are of particular
importance and occur near mid stance (the instant
207
Fig. 15.5 Peak knee flexion angle at mid stance is defined
by the midline of the thigh and the midline of the leg
when the body’s COM is directly over the foot):
peak knee flexion angle and peak ankle dorsiflex-
ion angle.
Peak Knee Flexion Angle Peak knee flexion
angle is defined in the same manner as knee flex-
ion at initial contact, i.e., the angle between the
midline of the thigh and the midline of the leg
(Fig. 15.5). This angle is highly predictive of peak
patellofemoral joint force, such that peak force
increases as knee flexion angle increases [18, 23].
Peak knee flexion angles near 45° are generally
recommended, although like all joint kinematic
values, this will vary with running speed.
Peak Ankle Dorsiflexion Angle Ankle dorsi-
flexion is defined by the midline of the leg rela-
tive to vertical (Fig. 15.6), with peak values
typically occurring shortly after mid stance.
Assessing peak ankle dorsiflexion during stance
may provide insights into calf muscle load and
Achilles tendon strain. For example, greater peak
ankle dorsiflexion requires the calf muscle-
tendon units to undergo greater stretch, possibly
208
Fig. 15.6 Peak ankle dorsiflexion angle at mid stance
is defined by the midline of the foot and the midline of
the leg
Fig. 15.7 Center of mass (COM) vertical excursion is determined by estimating the linear displacement of the COM
from its highest point at (a) mid flight to its lowest at (b) mid stance
A. Gallow and B. Heiderscheit
requiring the muscle fibers to operate at longer
lengths. These muscle-tendon kinematics have been
associated with increased risk of injury [24].
Additional Sagittal Measures
COM Vertical Excursion Vertical displace-
ment of the runner’s COM during the gait cycle
can impact both performance and joint loading.
This important measure is determined by esti-
mating the linear displacement of the COM from
its highest point (mid flight) to its lowest (mid
stance) (Fig. 15.7). If the COM undergoes a large
excursion, an increase in several kinetic variables
will occur including peak vertical ground reac-
tion force, braking impulse and peak knee exten-
sor moment [18]. Greater COM vertical excursion
is also associated with an increase in oxygen con-
sumption and reduced running economy [25, 26].
While a specific optimum value for COM excur-
sion has not been defined, 6–10 cm is a generally
acceptable range with the higher values more
typical for novice runners.
15 Clinical Aspects of Running Gait Analysis 209

Hip Extension and Pelvic Tilt Hip extension

and pelvic tilt are assessed during the push-off
phase of the running cycle, although the amount of
pelvic tilt may also be evaluated during mid stance.
Hip extension is the angle between the midline of
the thigh and midline of the pelvis, while pelvic tilt
is defined by the midline of the pelvis relative to
vertical. Although there is limited research regard-
ing lumbopelvic positioning in the sagittal plane in
runners, it’s an important feature to assess espe-
cially in those with low back or hip pain and in the
postpartum running population. Throughout the
running cycle, the pelvis demonstrates an average
anterior tilt position of 15–20° [27]. Anterior pel-
vic tilt and hip extension ROM are coordinated
motions, as runners who display decreased hip
extension ROM during push-off often show an
increase in anterior pelvic tilt [28]. Excessive
anterior pelvic tilt can be associated with high
hamstring tendinopathy, as well as low back pain
secondary to the associated increase in lumbar lor-
dosis. As running speed increases, runners appear
to achieve the necessary stride length by compen- Fig. 15.8 Trunk side bend is defined as the midline of the
trunk relative to vertical
sating at the pelvis and lumbar spine rather than
simply through hip extension [29].
reaction forces have peaked. The corresponding
Forward Trunk Lean Trunk lean is the angle position of the lower extremity provides insights
between the midline of the trunk and the vertical. into the neuromuscular systems’ ability to effec-
A small degree (5–10°) of forward trunk lean tively control joint and limb position.
may place the lower spine in a more neutral posi-
tion and facilitate placing one’s foot closer under Trunk Side Bend Trunk side bend, defined as
the COM at initial contact. midline of the trunk relative to the vertical, can
demonstrate motion in either the ipsilateral or
contralateral directions (Fig. 15.8). The total
Frontal Plane amplitude of motion is approximately 10° with
5° in each direction [27]. Increased ipsilateral
The frontal plane captures the runner best in the trunk lean is found in runners with both patello-
mid stance position of the gait cycle. Mid stance femoral pain and iliotibial band syndrome [30,
in the frontal plane allows for analysis of trunk 31], often times associated with increased motion
side bending, lateral pelvic drop, hip adduction of the pelvis in the frontal plane. Whether this is
angle, knee center position, foot COM position, secondary to hip abductor weakness, spinal
and rearfoot and forefoot positions. deformity, low back pain, poor neuromuscular
control, or other compensatory factors would
need to be determined through further testing.
Mid Stance
Lateral Pelvic Drop Lateral pelvic drop is
Mid stance is of key interest for assessing frontal defined by a line connecting the iliac crests rela-
plane measures as it reflects the end of loading tive to the horizontal (Fig. 15.9). During the first
response and the time in which the vertical ground half of stance phase, the iliac crest on the stance
210
Fig. 15.9 Lateral pelvic drop is assessed with a line con-
necting both iliac crests relative to horizontal
limb is slightly elevated relative to the contralat-
eral iliac crest, with this position commonly
referred to as contralateral pelvic drop, i.e., the
pelvis is laterally tilted toward the contralateral
(swing) side. Contralateral pelvic drop reaches a
maximum position of 5–7° near mid stance, with
females at the higher end of the range.
Knee Center Position The knee joint center
position is identified relative to a line connecting
the hip and ankle joint centers (Fig. 15.10). The
knee joint center should be located on this line,
indicative of the three major lower extremity
joints to be in alignment with each other. If the
knee center is located medial to the line, it would
indicate the presence of a dynamic valgus, with a
lateral location being a dynamic varus. Dynamic
valgus has been associated with knee joint injuries
including patellofemoral pain [32].
Mediolateral Distance from Foot to COM This
distance is determined from the heel relative to the
vertical line originated at the body’s COM (line of
A. Gallow and B. Heiderscheit
Fig. 15.10 Knee center position is measured as the
position of the knee joint center relative to a line connect-
ing the hip and ankle joint centers
gravity) (Fig. 15.11). This distance is dependent
on running speed, such that as speed increases
toward sprinting, the foot approximates and even
crosses over the line. However, at common recre-
ational running speeds (slower than 8:00 min/
mile), the foot will typically remain lateral to the
line. A crossover position at slower running speeds
may increase the risk for iliotibial band syndrome
and medial tibial injuries [33–35].
Rearfoot and Forefoot Position Rearfoot posi-
tion is defined by the midline of the heel relative
to the midline of the lower leg (Fig. 15.12).
Forefoot position is actually a transverse plane
alignment that can be assessed from the frontal
angle and involves determining how much of the
forefoot is visibly lateral to the rearfoot
(Fig. 15.13). In combination, these measures are
useful in characterizing the amount of foot pro-
nation that is occurring during running, which
may influence recommendations regarding shoes
and shoe inserts.
15 Clinical Aspects of Running Gait Analysis
Fig. 15.11 Mediolateral distance from the foot to center
of mass (COM) is determined from the position of the
heel relative to the body’s line of gravity, estimated as the
center of the pelvis
Fig. 15.12 Rearfoot angle is defined as the midline of the
heel relative to the midline of the leg
211
Fig. 15.13 Forefoot position involves determining how
much of the forefoot is visibly lateral to the rearfoot
Other Variables
Arm swing and trunk rotation should be also
assessed, especially as when a runner complains
of abdominal pain or breathing difficulties.
Transient abdominal pain during running occa-
sionally occurs for most runners, while some
experience it on a fairly consistent basis. At times
this abdominal pain can be debilitating to the run-
ner. Although this is an area of limited research,
trunk rotation and side bending with correspond-
ing rib approximation could be a component of
the problem. In a case study of two female run-
ners with recurrent transient abdominal pain,
decreasing this side bending motion while run-
ning, in addition to various other trunk and
breathing exercises, resulted in resolution of their
symptoms [36]. Arm swing while running helps
maintain balance and posture while counterbal-
ancing the effects of reciprocal leg swing, help-
ing to reduce the metabolic cost of running [37].
Further, when arm swing is eliminated, the trunk
appears to compensate with increased rotation,
which may affect breathing and abdominal
discomfort as described previously.
212
Summary
Becoming efficient and competent in clinical
video gait analysis takes time, effort, and prac-
tice. As the number of runners continues to grow,
the need for clinical video gait analysis as part of
a comprehensive injury management plan will
also increase. While this chapter has focused on
the importance of clinical video gait analysis for
the injured, a thorough history and physical
examination including review of training, nutri-
tion, and sleeping habits are important. The inte-
gration of these different factors will hopefully
lead to improved injury management and preven-
tion strategies for all runners.
Disclosure
Drs. Heiderscheit and Gallow do not have any
commercial or financial conflicts of interest to
disclose.
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