The Evaluation
Comprehensive Physical Therapy Evaluation for Runners: A Complete Guide
As a physical therapist working with runners, establishing a thorough evaluation process is crucial for identifying potential issues before they become injuries. This blog post details a comprehensive assessment protocol specifically designed for runners who are currently healthy but want to optimize performance and prevent future problems.
Introduction
Running is a demanding sport that places significant stress on the musculoskeletal system. Even "well" runners often have subtle biomechanical issues that, if left unaddressed, can lead to overuse injuries. A proactive evaluation can identify these movement patterns, strength deficits, and mobility restrictions before they cause pain or dysfunction. This evaluation is also effective for obtaining a whole body view of a runner suffering from a condition like hip impingement, medial tibial stress syndrome, patellofemoral pain, or other relatively mild conditions. Pain in one area is often due to dysfunction in another, so obtaining a holistic view of the athlete is key to treatment.
Here’s what we’ll be going through, organized by assessment area:
Lower Extremity Assessment
Bipedal squat from front and side
Unilateral squat
Craig’s test
Patellar glide
Core and Pelvic Assessment
Pelvic vs. shoulder mobility
Unilateral hip extension with 0° and 90° knee flexion
Ober test
Foot and Ankle Assessment
Ankle dorsiflexion
First ray dorsiflexion
Foot varus/valgus at rest
Single leg heel raise
Windlass test
Sit to stand navicular drop test
Toe yoga
Core and Functional Assessment
Vertical compression test
Lunge with overhead reach
Resisted bridge test
Chair of Death Squat
Lower Extremity Assessment
Bipedal Squat Assessment
Front View Analysis
When observing the runner perform a bilateral squat from the front, pay particular attention to knee alignment. The primary concern is dynamic valgus, where the knees collapse inward during the descent phase. This movement pattern indicates potential weakness in the hip abductors (particularly gluteus medius) and external rotators, which are crucial for maintaining proper lower extremity alignment during running.
What to watch for:
Knees tracking over the second toe throughout the movement
Equal weight distribution between both feet
Pelvic stability without dropping to either side
Foot pronation patterns during the descent
Red flags:
Knee valgus (knees moving inward)
Asymmetrical weight shifting
Foot collapse or excessive pronation
Side View Analysis
The side view of a squat reveals important information about hip and ankle mobility, as well as movement strategies that might impact running mechanics.
What to watch for:
Early heel rise during descent, which indicates limited ankle dorsiflexion
Knee-forward strategy, where the knees translate excessively forward rather than the hips moving backward
Trunk position relative to the lower extremities
Red flags:
Heels lifting before reaching 60° of knee flexion
Excessive forward lean of the trunk
Inability to achieve at least 90° of knee flexion
Unilateral Squat Test
This test assesses single-leg stability and control, which is particularly relevant for runners since running is essentially a series of single-leg stance phases.
Scoring protocol: Ask the runner to perform 7 single leg squats. Start with a score of 6 and deduct one point for each of the following:
Hands coming off hips (indicates balance challenges)
Trunk shift away from the stance leg
Pelvic drop on the non-stance side
Knee moving medial to the second toe
Elevation of the inside of the foot (supination)
Loss of balance (LOB)
Clinical significance: A score of 4 or less suggests deficits in hip strength, core stability, or neuromuscular control that should be addressed in a prevention program.
Craig's Test
This test assesses femoral anteversion or retroversion, which can significantly impact running mechanics.
Testing procedure:
Position the runner prone with knee flexed to 90°
Rotate the hip while palpating the greater trochanter
When the trochanter is most prominent, note the position of the tibia
Normal findings:
Tibia should be approximately 10-15° from vertical
Greater angles indicate increased femoral anteversion
Clinical significance: Abnormal femoral torsion can lead to altered running mechanics, including increased internal rotation at the hip and subsequent compensations throughout the kinetic chain.
Patellar Glide
This test assesses the mobility of the patella within the trochlear groove.
Testing procedure:
With the knee relaxed in slight flexion, glide the patella medially and laterally
Note the amount of movement in each direction
Normal findings:
The patella should glide approximately 1/3 of its width in each direction
Movement should be smooth and pain-free
Clinical significance: Limited patellar mobility can lead to tracking issues during running, potentially contributing to patellofemoral pain syndrome, particularly with high mileage.
Core and Pelvic Assessment
Pelvic vs. Shoulder Mobility
This test evaluates the runner's ability to dissociate pelvic and shoulder rotation, which is crucial for efficient running mechanics and energy transfer.
Testing procedure:
Have the runner stand with feet shoulder-width apart
Ask them to rotate their pelvis independently of their shoulders
Then have them rotate their shoulders while keeping the pelvis stable
Clinical significance: Limited dissociation between these segments can lead to inefficient running mechanics, increased energy expenditure, and potentially excessive rotational forces through the lumbar spine.
Unilateral Hip Extension Assessment
Prone Position
Testing procedure:
Position the runner prone on the table
Ask them to extend one hip while keeping the lumbar spine neutral
Measure the angle of hip extension
Normal findings:
15 degrees of hip extension independent of lumbar movement
Test is failed if excessive lumbar extension occurs instead of isolated hip extension
90° Knee Flexion
Testing procedure:
Position the runner prone with the test knee flexed to 90°
Ask them to lift the thigh off the table
Normal findings:
0 degrees of hip extension with the knee bent to 90°
This isolates the iliopsoas muscle
Clinical significance: Limited hip extension is extremely common in runners and can lead to compensatory lumbar extension, anterior pelvic tilt, and inefficient stride mechanics.
Ober Test
This test assesses IT band and tensor fascia latae (TFL) flexibility, which is crucial for lateral hip stability and preventing issues like IT band syndrome.
Testing procedure:
Position the runner in side-lying with the test leg on top
Stabilize the pelvis and bring the top leg into hip extension and neutral rotation
Allow the leg to adduct toward the table
Normal findings:
More than 10 degrees of adduction is normal
Less than 10 degrees indicates IT band/TFL tightness
Important considerations:
Maintain neutral hip rotation during testing
Avoid allowing the pelvis to rotate during the test
Foot and Ankle Assessment
Ankle Dorsiflexion
Limited ankle dorsiflexion is a common finding in runners and can lead to a variety of compensatory movements during running.
Testing procedure:
Position the runner in a lunge position with the test foot forward
Have them bend the front knee while keeping the heel on the ground
Measure the angle between the tibia and the ground
Normal findings:
Ideally 15-20° of dorsiflexion
Less than 10° is considered restricted
Clinical significance: Restricted dorsiflexion can lead to early heel rise during running, excessive pronation, increased stress on the plantar fascia, and altered knee mechanics.
First Ray Dorsiflexion
This assessment evaluates the mobility of the first metatarsal, which is crucial for proper push-off mechanics during running.
Testing procedure:
With the ankle in neutral, grasp the first metatarsal head and move it into dorsiflexion
Repeat with the ankle at 10° dorsiflexion
Normal findings:
80° of mobility with the ankle in neutral
30° with the ankle at 10° dorsiflexion
Clinical significance: Limited first ray mobility can lead to inefficient push-off, increased pressure on the lateral foot, and potential issues like sesamoiditis or plantar fasciitis.
Foot Varus/Valgus at Rest
This assessment evaluates the static alignment of the forefoot relative to the rearfoot.
Testing procedure:
Position the foot in subtalar neutral
Observe the alignment of the forefoot relative to the rearfoot
Normal findings:
Slight forefoot varus (2-4°) is considered normal
Excessive varus or valgus can indicate structural issues
Clinical significance: Forefoot varus often leads to compensatory pronation during running, while forefoot valgus may contribute to lateral foot overload and reduced shock absorption.
Single Leg Heel Raise
This test assesses calf strength, endurance, and first ray stability during push-off.
Testing procedure:
Have the runner hold onto something lightly for balance
Ask them to perform 20 single-leg heel raises
Observe quality of movement, particularly push-off through the first ray
Normal findings:
Completion of 20 repetitions with good form
Stable push-off through the first ray
Maintenance of subtalar neutral
Clinical significance: Weakness or poor control during this test can indicate risk for Achilles tendinopathy, plantar fasciitis, or medial tibial stress syndrome.
Windlass Test
This test evaluates the integrity of the plantar fascia and its role in the windlass mechanism during push-off.
Testing procedure:
With the runner seated, dorsiflex the great toe
Observe for tightening of the plantar fascia and raising of the medial arch
Normal findings:
Visible raising of the arch with great toe extension
No pain with the maneuver
Clinical significance: A dysfunctional windlass mechanism can lead to inefficient push-off and increased strain on the plantar fascia during running.
Toe Yoga
This assessment evaluates intrinsic foot muscle control and dexterity, which is critical for foot stability during the push-off phase of running.
Testing procedure: Ask the runner to:
Keep the heel on the ground
Lift just the big toe while keeping the other toes down
Keep the big toe down while lifting the other toes
Alternate between positions
Clinical significance: Difficulty performing these movements indicates poor intrinsic foot muscle control, which can contribute to excessive pronation, arch collapse, and inefficient push-off mechanics during running.
Sit to Stand Navicular Drop Test
This test assesses the dynamic control of the medial longitudinal arch during functional loading.
Testing procedure:
Mark the height of the navicular tuberosity while seated
Have the runner stand and remeasure the height
Calculate the difference between measurements
Normal findings:
Less than 10mm of drop is considered normal
Greater than 10mm indicates excessive pronation
Clinical significance: Excessive navicular drop during functional loading indicates poor dynamic control of the medial longitudinal arch, which can lead to overuse injuries such as plantar fasciitis, posterior tibial tendinopathy, and medial tibial stress syndrome.
Core and Functional Assessment
Vertical Compression Test
This test assesses the ability of the core muscles to stabilize the lumbar spine under load.
Testing procedure:
Have the runner stand in a neutral position
Apply a moderate downward force through the shoulders
Normal findings:
Maintenance of neutral lumbar spine position
No observable collapse or excessive movement
Clinical significance: Failure to maintain lumbar position indicates poor core stability, which can lead to excessive movement and potential injury during the impact phase of running.
Lunge with Overhead Reach
This functional test assesses the integration of core stability with lower extremity movement.
Testing procedure:
Have the runner hold a 5-pound weight overhead
Ask them to perform a forward lunge
Observe trunk and pelvic position
Normal findings:
Maintenance of neutral spine throughout the movement
Stable pelvis during the lunge phase
Clinical significance: Lumbar collapse during this test indicates poor integration of core stability with lower extremity movement, which can lead to inefficient running mechanics and increased injury risk.
Resisted Bridge Test
This test assesses gluteal function and potential hamstring dominance.
Testing procedure:
Have the runner perform a bridge
Apply downward resistance to their pelvis as they march one leg at a time
Observe for pelvic level and muscle activation patterns
Normal findings:
Maintenance of level pelvis during marching
Primary activation of gluteal muscles
Red flag:
Hamstring cramping during the test indicates gluteal inhibition and hamstring dominance
Clinical significance: Gluteal inhibition is common in runners and can lead to hamstring overuse, excessive anterior pelvic tilt, and increased lumbar stress during running.
Chair of Death Squat
This challenging functional test assesses hip and ankle mobility, as well as overall lower extremity control.
Testing procedure:
Have the runner stand with each foot against a chair leg, facing the seat and hold a dowel along their spine, touching each segment from T1-L5
Have them perform a deep squat with feet flat and observe for forward knee drive
Ask them to hold the position for 30 seconds
Normal findings:
Ability to achieve and maintain a deep squat position
No trunk flexion or heel rise
Clinical significance: Difficulty with this test indicates limitations in hip and/or ankle mobility, or poor motor control, which can lead to compensatory movement patterns during running.
Optional - Running Analysis Section
Performing a treadmill running assessment is a more advanced skill, but important to get a full picture of a runner. Here’s how to do it in brief.
Treadmill Running Assessment
Observing the runner in their natural movement pattern provides crucial information about dynamic function.
Testing procedure:
Ask the runner permission to use their phone to record them to mitigate privacy concerns
Record video from behind and from the side
Have the runner maintain their typical training pace
Allow them to run for at least 3 minutes to allow for normal movement patterns to emerge
Record a random segment of approximately 15 seconds after the 3 minute period
What to watch for:
Cadence (ideally 165-190 steps per minute)
Stride length and symmetry
Foot strike pattern (forefoot, midfoot, rearfoot)
Vertical oscillation (excessive bouncing wastes energy)
Foot strike position (ideally under the center of mass)
Arm swing and counter-rotation of the trunk
Pelvic stability during stance phase
Clinical significance: Running evaluation provides functional context for static findings and reveals compensations that may not be apparent during clinical tests. Video analysis allows for frame-by-frame review to identify subtle movement impairments.
Conclusion
A comprehensive PT eval for runners should assess the entire kinetic chain, from the foot and ankle through the knees, hips, and core. By identifying potential issues before they become symptomatic, you can develop targeted prevention programs that address individual runner's needs.
Remember that these findings should be interpreted in the context of the runner's overall presentation, training history, and goals. A single "abnormal" finding doesn't necessarily indicate pathology, but patterns of dysfunction across multiple tests can highlight areas that need attention.
We’ve put together a PDF of all of these tests, complete with what to look for and note-taking sections, organized by patient position to be as efficient as possible. Download it to use in your clinic and get the best runner eval as efficiently as possible. All these tests can be performed in less than 10 minutes, once you’re experienced with applying them. The layout in this document will help your exam be efficient so you can get it all done in one visit.