Running drills: changing the step – Knowledge

1. What this article is about

Running drills mean practising single parts of running on their own. You lift the knee higher than usual. You pull the heel towards your buttock. You land further forward on the foot. Then you run normally again and take something of it with you.

In athletics clubs this collection is called the running ABC. The same stimuli appear in physiotherapy. There they are called gait retraining.

This article covers three uses:

• Sport. You run regularly and would like fewer complaints.
• Rehabilitation. You are coming back to running after an injury or an operation. Or you have complaints that return every time you run.
• Safe walking in older age. You would like to walk over uneven ground without falling.

All three train the same systems. Coordination, strength and balance appear everywhere. The choice of exercises and the dose differ.

One point belongs at the start. Useful studies exist for individual adjustments. Step rate in running and balance training in older age are among them. For the drill collection as a whole we found no study. What this article says about it rests on the studies of its parts and on experience.

2. What the drills train

The common exercises target three things. Research on gait retraining studies the same three [1], [5].

• Step rate. How many steps do you take per minute?
• Foot strike. Which part of the foot meets the ground first, and how far in front of your body?
• Control of pelvis and hip. How steady does your pelvis stay while one leg carries you?

All running drills are exaggerations. They make a part of the movement larger than it ever is while running. That is their purpose. An exaggerated movement is easier to feel than a subtle one.

2.1 The six basic drills

Do the drills on level, firm ground. A stretch of 20 to 30 metres is enough. Walk back loosely between runs.

High knees. You move forward while lifting the knees high.

1. Stand tall and move forward slowly.
2. Lift one knee to hip height with every step.
3. Land under your body, with the ball of the foot first.
4. Let the arms swing in opposition.

This drill trains knee lift and the position of the pelvis. Most common error: the upper body leans back so that the knee comes higher. Stay lower and upright instead.

Butt kicks. You pull the heel up and back towards the buttock.

1. Move forward with short steps.
2. Pull the heel towards the buttock with every step.
3. Keep the thighs nearly vertical.
4. Pull the toes up towards the shin.

This drill trains the fast folding of the leg after push-off. Most common error: the knee travels forward, and the heel meets the thigh rather than the buttock.

Ankling. You take very short steps and work from the ankle only.

1. Take very small steps, barely a foot length long.
2. Roll over the ball of the foot and extend the ankle fully.
3. Keep the knees almost straight.
4. Pull the toes up again before every landing.

This drill trains the calf and the tendons below it. It is the least spectacular of the six and for many the hardest.

Skipping. You combine the knee lift with a small hop.

1. Start as in high knees.
2. Push off the ground briefly with every step.
3. Land over the ball of the foot and stay springy.
4. Keep ground contact short.

This drill trains the spring in the foot and calf. Most common error: the hops become high rather than fast.

Skip for height. You hop upwards over alternate legs.

1. Run in and hop upwards on every second step.
2. Drive the free knee forward and up.
3. Swing the opposite arm strongly.
4. Land softly over the ball of the foot.

This drill combines push-off strength with the timing of arm and leg.

Bounding. You run in long, slow leaps.

1. Take a few running steps to start.
2. Push off far forward and up with every step.
3. Stay in the air as long as you can.
4. Land under your body and continue immediately.

This drill is the most demanding of the six. It loads the Achilles tendon heavily. Add it once the other five run cleanly.

2.2 What has been studied about the drills themselves

For the drill collection as a whole we found no study that tested it against anything else. Two neighbouring areas do have evidence.

First, the individual adjustments. Controlled studies exist for step rate and foot strike. They appear in section 3 and section 4.

Second, strength and jump training. A review of studies in middle- and long-distance runners found running economy 2 to 8 per cent better after strength training [7]. Running economy means you use less oxygen at the same pace. That review recommends two to three strength sessions per week [7].

Bounding and skipping belong to jump training. The link to running economy is therefore plausible. What those studies tested was a full strength training programme rather than ten minutes of drills [7].

3. What a higher step rate does

Step rate is the best studied adjustment. It is also the simplest. You need no laboratory and no equipment for it.

In a laboratory study 45 recreational runners ran on a treadmill. They ran at their usual step rate and at 5 and 10 per cent above and below it [3]. At a higher step rate the energy absorbed at knee and hip on landing fell. Step length, the up-and-down movement of the centre of mass and the braking impulse on landing fell as well. At 10 per cent more steps the inward tilt at the hip fell too [3].

A review with meta-analysis summarised the controlled studies [1]. Step rate training raises step rate. It also lowers the loading rate. Loading rate means how fast the force rises when your foot lands. The authors rate the certainty of this result as moderate [1].

For the effect on pain the data were too sparse. Two studies found fewer injuries in the year after gait retraining [1].

3.1 How to measure and change your step rate

Count your steps at your usual pace. Use a flat stretch without bends.

1. Run easily for five minutes.
2. Count for 30 seconds how often the right foot lands.
3. Multiply that number by four. This gives your steps per minute.
4. Repeat the count twice and take the middle value.

Most recreational runners land between 155 and 175 steps per minute. A single value says little on its own. It varies widely between people, and it rises with pace.

If you want to raise it, proceed like this:

1. Set a metronome 5 per cent above your value. At 160 steps that is 168.
2. Run two to three minutes in time with it. Keep your pace unchanged.
3. Run five minutes without the beat.
4. Repeat this alternation three to four times in a session.
5. Stay at 5 per cent for two to three weeks before moving to 10 per cent.

Your steps become shorter in the process. Your pace stays the same because you take more of them. Many watches display step rate and can give the beat. This procedure is our practice suggestion. The studies set the size of the increase [1], [3], not the weekly plan.

3.2 What a study in beginners showed

320 people who were new to running were allocated at random to two groups [2]. 166 people received eight training sessions over two weeks. A screen showed them continuously how hard they were landing. Their task was to run more quietly. 154 people ran on the treadmill in the same way, without this feedback.

The loading rate fell clearly in the trained group. One year later the complaints had been counted. In the trained group 16 out of 100 people had developed a running complaint. In the comparison group it was 38 out of 100 [2].

Three things belong with that figure:

• It comes from a single study.
• The participants were beginners. This group gets injured more often than experienced runners anyway. Across 13 studies, beginners had 17.8 complaints per 1'000 hours of running and experienced runners 7.7 [4].
• The complaints were reported by the participants themselves.

The difference is large enough to deserve attention. It has also not yet been repeated in a second study.

4. What foot strike changes

The second adjustment is the part of the foot that touches the ground first. Many people land on the heel. Gait retraining away from the heel measurably changes the knee angle at the moment of landing [1]. Running economy did not improve with it. The certainty of this result is low, because few studies exist [1].

One review combined the available studies with the assessments of experienced clinicians [5]. For a switch from the heel to the midfoot or forefoot it found limited evidence in individual conditions. The clinicians surveyed use gait retraining mainly for tendon complaints and for bone overload [5].

The redistribution matters. Landing further forward unloads the knee and loads the calf and Achilles tendon more [5]. This change therefore suits people with knee problems and suits an irritated Achilles tendon poorly.

In practice this means: foot strike is a tool for certain complaints. As a general recommendation for everyone who runs, the evidence does not carry it.

5. How to fit the drills into your week

Our suggestion for healthy runners:

1. Run easily for ten minutes.
2. Do three to four drills over 20 to 30 metres each.
3. Repeat each drill twice.
4. Then run your planned session.
5. Include this once or twice a week, ideally before the fast sessions.

That takes ten to fifteen minutes. This dose comes from experience. We found no study comparing different doses of running drills.

One note on what matters most: how fast you increase your training volume affects your complaints more than the fine points of your technique. Beginners get injured more than twice as often per hour of running as experienced runners [4]. Cleanly executed drills are no substitute for a calm build-up.

6. Gait retraining in rehabilitation

In rehabilitation the whole drill collection is rarely the focus. Usually one single element is changed, chosen to match the complaint.

6.1 Pain at the front of the knee

With pain at the front of the knee (patellofemoral pain) the pelvis often drops on the side of the swinging leg. The standing leg tilts inwards at the same time.

In one study twelve people with this condition and this movement pattern ran to the beat of a metronome [6]. Their step rate was raised by 10 per cent in a single session. After four weeks and after three months the drop of the pelvis and the inward tilt of the hip were smaller. Pain and function had improved. Participants ran more kilometres per week and got further before the pain started [6].

This study included twelve people and had no comparison group. Part of the improvement would have occurred without the change as well. As a pointer to where practice is worthwhile, it is useful.

6.2 Pain along the shin bone

Pain along the inner edge of the shin bone (medial tibial stress syndrome) mainly affects people who are starting or restarting running.

A meta-analysis of twelve studies with 8'197 people examined preventive measures [8]. Neuromuscular training lowered how often the condition occurred. The authors rate the certainty of this result as high. Insoles that limit the inward roll of the foot worked as well, with moderate certainty. Shock-absorbing insoles showed no effect [8].

A meta-analysis of 22 papers found five features that accompany the condition [9]: female sex, higher body weight, a foot arch that drops further, a previous running injury and greater outward rotation at the hip. These features describe groups. For a single person they predict little.

In practice this means: strengthening the calf and foot muscles has better evidence here than technique work. The ankling drill from section 2.1 fits well with it.

6.3 What technique work achieves

Gait retraining changes the load. It leaves running economy unchanged [1]. It therefore makes you gentler on your joints rather than faster.

Three things belong with any change:

• Feedback. Metronome, watch, mirror, video or the therapist's voice. Without feedback little changes [1], [5].
• Time. The studies trained over two to eight weeks with several sessions per week [1], [2].
• Fading the help. At the start the feedback runs continuously. Later it comes only in samples. At the end you run without it.

Technique is one of several starting points. Load management and strength training stand alongside it [5]. How strength is built up is described in our guide Strength training.

7. Foot position in knee osteoarthritis

The following section is about walking. It belongs here because the same logic applies as in running: change one element of the movement in order to unload a structure.

In osteoarthritis of the inner part of the knee, the inner side carries more load than the outer side. Foot position during walking affects that distribution.

7.1 What the turn changes at the knee

When walking, the toes usually point somewhat outwards. Clinicians call this angle the foot progression angle. In a study of 180 people with osteoarthritis of the inner knee it averaged 11.4 degrees [10]. The spread was wide. Values ranged from 2.2 degrees inwards to 28.4 degrees outwards.

The researchers calculated, for the same steps, what would have happened without this outward turn [10]. The measure was the moment that tilts the knee inwards during stance. This moment serves as a stand-in for the load on the inner side of the knee.

With the outward turn this moment was 11.7 per cent smaller in early stance. Part of it reappeared as a flexion moment, which rose by 25.0 per cent. In late stance the peak value was 34.4 per cent smaller [10].

Two limits belong with this. That paper trained nobody. It compared two ways of calculating the same steps. And the moment is a calculated value rather than a measured load inside the joint.

7.2 How such training runs

A feasibility study had 15 people with osteoarthritis of the inner knee practise for ten weeks [11]. The target was an outward turn 10 degrees larger than their own starting value. The target therefore followed the person.

The participants carried the change through. Their angle during self-selected walking increased. Pain scores fell, and so did the calculated load at the knee [11]. Five of the 15 people developed temporary complaints in hip or knee while getting used to it. These lasted at most two weeks [11].

This study had no comparison group and included 15 people. It shows that the change is feasible. About its effect on pain compared with no change it says nothing.

This is how the practice runs:

1. Your therapist measures your current foot progression angle.
2. You practise standing first. Turn the whole leg outwards from the hip. The foot stays unchanged relative to the lower leg.
3. You walk slowly over a short distance and watch yourself in a mirror or on video.
4. You carry the position over into your normal walking pace.
5. You practise for a few minutes daily on routes you walk anyway.

A verbal image makes this easier. Picture a clock face on the floor. Your toes point at ten and at two o'clock rather than at twelve. The turn comes from the hip. The whole leg turns with it.

7.3 Why the direction is checked

An outward turn helps some people and not others. In one study 107 people with osteoarthritis of the inner knee walked with four different foot positions [12]. They turned the toes 5 and 10 degrees inwards and outwards.

For each person the most favourable of these four positions was then chosen. With this personally chosen position the peak moment fell by at least 5 per cent in 70 out of 100 people. When the same position was prescribed to everyone, this succeeded in only 23 to 57 out of 100 people, depending on which position was chosen [12].

Some people therefore benefit from an inward turn. A single recommendation for everyone leaves the load unchanged in those people.

There is a reassuring finding for the hip. In 50 people whose knee load fell with the change, the moment at the hip fell as well [13]. In 74 out of 100 of these people the total load at the hip fell [13].

For you this means: this change belongs in the hands of a professional who checks your direction. More about osteoarthritis itself is in our guides Osteoarthritis and Hip osteoarthritis.

8. When you run again after an operation

After an anterior cruciate ligament reconstruction, after meniscus surgery or after a joint replacement, technique work comes late. First the leg has to carry the load.

A review analysed 201 studies after cruciate ligament reconstruction [14]. It found 205 statements about when running was permitted. The median point was 12 weeks after the operation. The range ran from 5 to 39 weeks. Fewer than one in five studies additionally named criteria from the clinical examination, from strength measurements or from tests [14].

A fixed number of weeks says little about an individual knee. Healing runs at different speeds in different people. The review therefore recommends combining time with tested criteria [14].

These criteria were named most often [14]:

• full knee range of motion compared with the other side
• strength of at least 70 per cent compared with the other leg
• hop tests with a similar threshold between sides
• a normal, pain-free walking pattern in daily life

The return then usually starts as an alternation of walking and running. It moves stepwise into running alone. The technique work from section 6 comes last.

This order transfers to other operations in principle. For running after a joint replacement the evidence is thinner than after cruciate ligament reconstruction. More on this is in our guides Knee replacement and Meniscus.

9. How to come back after a muscle strain

Two states are often confused.

Muscle tightness is a raised resting tension in the muscle. It often appears in the calf or the front of the thigh. Common triggers are a training increase that was too fast and a technique that constantly overloads one muscle group. This is where the drills work on the cause.

A muscle strain is an injury of the muscle tissue. It usually has a clear moment, often while sprinting or braking sharply. Most often it affects the back of the thigh and the calf.

For the way back to sprinting there is a published proposal with three stages [15]. This proposal comes from the authors' clinical experience and from related studies. There is no study that tested it against another build-up.

1. Build-up. A programme of walking and running over several weeks. The aims are pain-free everyday activity and strength of about 70 per cent compared with the other side [15].
2. Introduction. Speed rises stepwise to around 50 to 75 per cent of your top speed. Every session stays pain-free [15].
3. Sprinting. Approaching full speed follows once strength, range of motion and freedom from pain are stable across several sessions [15].

Progress depends on met criteria rather than on the calendar. Technique work joins in at the second stage. Often only then does it become clear whether an unfavourable technique contributed to the injury.

We have a separate article on strains at the back of the thigh: Hamstring injury.

10. What shifts in older age

Anyone running in older age can continue to use the drills. Two things change.

Recovery takes longer. After a session with jumps, plan more time before the next hard session.

Strength and speed need more attention. They decline faster over the years than endurance does. Strength training counters this. More on it is in our guides Strength training and Muscle weakness in older age.

For the larger group the aim shifts. Many people no longer run and would like to walk safely. Then walking safety is what counts. That means the ability to answer a trip, uneven ground or a sudden change of direction without falling.

11. What exercise achieves against falls

The evidence on this question is unusually good. A Cochrane review summarised 108 randomised studies with 23'407 participants [16]. The average age was 76 years. 77 out of 100 participants were women. All lived at home.

The two main results in absolute numbers [16]:

• In the comparison groups there were 850 falls per 1'000 people per year. In the exercise groups there were 195 falls fewer. The confidence interval runs from 144 to 246 falls fewer.
• In the comparison groups 480 out of 1'000 people fell at least once per year. In the exercise groups there were 72 people fewer. The confidence interval runs from 52 to 91 people fewer.

The review rates the certainty of these two results as high [16]. Keep the baseline of 850 falls per 1'000 people per year in mind. It helps you place the percentages that follow.

The review also examined what the effect depends on [16], [17]:

• Whether a study included only people at raised risk of falling made no difference to the result.
• Whether participants were over 75 years old made no difference to the result.
• Whether training was individual or in a group made no difference to the result.
• When a health professional led the training, usually a physiotherapist, the effect was larger.

The form of exercise mattered. Balance and functional exercises are the best studied, with 39 studies and 7'920 participants. They lowered the rate of falls by 24 per cent [17]. Programmes combining several types of training, usually balance and functional exercises together with resistance training, lowered it by 34 per cent. This second figure comes from 11 studies with 1'374 participants and is correspondingly less certain [17].

Adverse events occurred. They were mostly minor and concerned muscles and joints [16].

What an assessment before training looks like is described in our guide Assessing the risk of falling.

12. The Otago programme

The Otago programme is a home programme of strength and balance exercises. A physiotherapist assembles it, demonstrates it at home and progresses it over several visits. A walking programme is added [18].

The first study of it ran in New Zealand [18]. 233 women aged 80 and over took part. 116 received the programme, 117 received usual care and the same number of visits.

After one year there had been 152 falls in the comparison group and 88 in the exercise group [18]. Per person and year that is 1.34 against 0.87 falls. A first fall with an injury also occurred less often in the exercise group [18].

A later summary analysed seven studies with 1'503 participants [19]. The average age was 81.6 years. The rate of falls was lower in the exercise groups. For serious and moderate fall-related injuries the analysis found no difference [19].

The same analysis found fewer deaths within one year in the exercise groups [19]. How many people this concerned is not stated in the summary.

One figure from the same analysis belongs to an honest account. Of 747 people who took part for twelve months, 36.7 per cent were still exercising three times a week or more at the end [19]. An effective programme only helps while it takes place.

13. The LiFE programme

LiFE stands for Lifestyle-integrated Functional Exercise. The programme builds balance and strength stimuli into actions you carry out every day anyway [20].

The study of it ran in Sydney [20]. People aged 70 and over could take part if they had fallen twice in the preceding year, or once with an injury. 317 people were allocated at random to three groups. 107 received LiFE. 105 received a conventional exercise programme three times a week. 105 received a programme of gentle movement exercises as a comparison.

Over twelve months there were 172 falls in the LiFE group, 193 in the group with the conventional programme and 224 in the comparison group [20]. Per person and year that is 1.66 against 1.90 against 2.28 falls. The difference between LiFE and the comparison group corresponds to 31 per cent fewer falls. The difference between the conventional programme and the comparison group was statistically uncertain [20].

In addition, standing balance, ankle strength, everyday function and participation in life outside the home improved in the LiFE group [20].

13.1 The three balance principles

All balance exercises in the programme follow three principles [20].

• Reduce the base of support. Less contact area forces your nervous system into finer corrections. Examples: placing the feet one behind the other, standing on one leg.
• Shift your weight to the limit. You practise finding your balance again before it is lost completely. Examples: leaning sideways, rocking onto the toes and heels.
• Step over obstacles. You practise lifting the foot while standing briefly on one leg. Examples: stepping over a threshold, a cushion or the edge of a rug.

13.2 The four ways to load a muscle

The programme works with your own body weight and without equipment. The load rises through four adjustments [20].

• Repeat more often. Take the stairs several times rather than once with everything at once.
• Move more slowly. Sit down under control rather than dropping.
• Support yourself less. Stand up without armrests.
• Increase the range. Bend the knees further when picking something up.

The target muscles are chosen deliberately. The foot lifters and the calf carry the foot over the ground while walking. The front and back of the thigh carry you when standing up and climbing stairs. The muscles at the side of the hip keep the pelvis level while one leg carries you.

13.3 Why the home trains with you

Participants arrange their home so that everyday actions demand more. The toothpaste goes into the lower cupboard. The remote control lies by the television rather than on the table.

The purpose is regularity. Reaching for the toothpaste is its own reminder. A programme on a sheet of paper needs a decision.

13.4 A version for younger seniors

A more demanding version of LiFE for people aged 60 to 70 has been developed. It is called aLiFE. In a preliminary study over four weeks, 31 participants and 6 trainers tried the programme out [21]. Both sides received it well. Obstacles were named too: extensive study paperwork, busy daily lives and embarrassment about exercising in public [21].

This preliminary study examined feasibility. Whether aLiFE prevents falls remains open [21].

14. Otago or LiFE: which suits you?

Both programmes were studied in people at raised risk of falling. Both showed fewer falls than their comparison groups [18], [20]. They differ in construction.

• Otago has fixed exercises with sets and repetitions. A professional doses and progresses them. Progress can be read off. It needs a fixed slot in your week.
• LiFE has no fixed exercise times. The stimuli hang on everyday actions. The dose is harder to determine. In exchange the start is easier if a fixed programme puts you off.

A third option belongs to a complete account: doing nothing. Then the figures of the comparison groups from section 11 apply. Out of 1'000 people there, 480 fell at least once within a year [16].

In practice the two can be combined. Otago gives the start a structure. LiFE keeps the practice alive over years.

15. Practising steps and answering perturbations

When you trip, fractions of a second decide the outcome. Whoever places a step in time catches themselves. That step can be practised.

One review summarised seven randomised studies with 660 participants [22]. What was practised were steps on a signal and steps forced by a perturbation. The training groups fell less often than the comparison groups. Reaction time, balance and walking improved. Strength did not change [22]. The effect therefore arises through the speed of response.

A more recent review examined training with deliberate perturbations [23]. Here a professional pulls or pushes the practising person off balance. On a treadmill this happens through sudden changes of speed. The rate of falls was 23 per cent lower than in the comparison groups, and falls with injury 24 per cent lower [23]. Programmes with at least six hours of practice reached 33 per cent [23].

The review found the improvement mainly in catching the balance. On ordinary walking this training had little effect [23]. It therefore adds to strength and balance training rather than replacing it.

16. Walking and thinking at the same time

In daily life you rarely just walk. You talk while doing it, you look for a house number, you carry something. How much attention walking itself demands therefore affects your safety.

A review with meta-analysis analysed 44 studies with 2'782 older people [24]. What was trained was walking together with a thinking task. Balance in motion and everyday mobility improved. The number of falls fell [24].

The same analysis gives figures on dose [24]. For balance in motion, 30 minutes three times a week over four weeks were enough. The tasks were moderately demanding. For everyday mobility it took 50 minutes three times a week over 13 weeks. Both figures apply to people who attended almost all sessions.

Examples of such tasks: counting backwards in threes, saying the days of the week backwards, finding words beginning with a given letter. Practise this with someone else present at first.

Detailed instructions for both of these building blocks are in our section Thinking and stepping training. It holds five exercises with three levels each, together with the evidence behind them.

17. Exercises for safe walking

These exercises come from the programmes and reviews in sections 11 to 16. Start at a kitchen counter or at the back of a chair. Hold on at first and let go once it feels safe.

Standing up without hands.

1. Sit on the front half of a chair.
2. Fold your arms across your chest.
3. Stand up and sit down again slowly.
4. Do 10 repetitions. Repeat the whole thing twice.

Heel raises in standing.

1. Stand hip-width apart and hold on lightly.
2. Lift both heels slowly off the ground.
3. Lower them again over three seconds.
4. Do 12 repetitions. Repeat the whole thing twice.

Tandem stance.

1. Place one foot directly in front of the other, heel to toes.
2. Hold the position for 20 to 30 seconds.
3. Change the front leg.
4. Do this twice per side.

Single-leg stance.

1. Stand on one leg and hold for 20 to 30 seconds.
2. Progress in this order: eyes open, then turning the head, then on a mat.
3. Do this twice per side.

Stepping over obstacles.

1. Lay three rolled-up towels on the floor a metre apart.
2. Step over them while walking, without stopping.
3. Look ahead rather than at your feet.
4. Walk the stretch six times.

Changing direction on command.

1. Walk around a room.
2. A second person calls "stop", "left" or "right".
3. Answer as fast as you can.
4. Practise for two minutes, then take a break.

Changing surfaces. Walk deliberately over grass, gravel and forest floor. Start in daylight and on familiar paths.

Our suggested dose: two to three times a week as a block of 20 to 30 minutes. Or several times a day built into existing routines, as LiFE does it. The evidence behind this is in sections 11 to 16.

Causes of falls and programmes are covered in more detail in our guide Fall prevention.

18. When to get in touch

Make an appointment with your doctor if one of these applies:

• You have fallen twice or more in the past year.
• You have fallen once and injured yourself doing so.
• Your walking pattern has changed within days or weeks.
• You become dizzy while walking or standing up.
• One leg feels numb, or it gives way while walking.

Go to the emergency department at once if you notice one of these:

• You suddenly cannot walk or cannot bear weight on one leg.
• Your speech, your vision or one side of your face changes suddenly.
• You lose control of bladder or bowel and have back pain at the same time.
• One calf swells, becomes warm and hurts without any injury.

Contact physiotherapy if one of these applies:

• Your running complaints return after every break.
• You want to run again after an operation and do not know your criteria.
• You feel unsteady while walking and avoid certain routes because of it.
• You would like your foot position checked for knee osteoarthritis.

19. What you should know

• The drills train three things: step rate, foot strike and control of pelvis and hip [1], [5].
• Studies of the drill collection as a whole are missing. What is documented are the individual adjustments and strength and jump training [7].
• More steps per minute lower the load at knee and hip. Five to ten per cent more steps are enough [3].
• In beginners there is an injury figure for this. After two weeks of training, 16 out of 100 people had a running complaint one year later. In the comparison group it was 38 out of 100 [2]. This figure comes from a single study.
• Gait retraining makes you gentler on your joints rather than faster [1].
• With pain at the front of the knee, look at the pelvis [6]. With shin pain, strengthening has better evidence than technique [8].
• In knee osteoarthritis a changed foot position unloads the inner side of the knee [10]. The favourable direction differs between people and is checked [12].
• After surgery, criteria count rather than the calendar. Those named are full range of motion, 70 per cent strength between sides, hop tests and a pain-free walking pattern [14].
• After a strain, speed increases in stages [15].
• Exercise lowers falls in older age. Out of 1'000 people, 480 in the comparison groups fell at least once within a year. In the exercise groups there were 72 people fewer [16].
• Balance and functional exercises have the best evidence [17]. Instruction by a professional strengthens the effect [16].
• Otago and LiFE are the two longest studied programmes [18], [20]. Otago gives structure, LiFE gives everyday practicality.
• Steps on a signal and answers to perturbations add to the training [22], [23].
• Walking with a thinking task improves balance and mobility [24].
• The building blocks are similar across the lifespan. Balance, strength, speed of response and trunk control matter for a 25-year-old runner and an 80-year-old walker alike. Pace and volume differ.

References

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[1] Doyle E, Doyle TLA, Bonacci J, Fuller JT. The Effectiveness of Gait Retraining on Running Kinematics, Kinetics, Performance, Pain, and Injury in Distance Runners: A Systematic Review With Meta-analysis. Journal of Orthopaedic & Sports Physical Therapy. 2022;52(4):192–206. https://doi.org/10.2519/jospt.2022.10585

[2] Chan ZYS, Zhang JH, Au IPH, An WW, Shum GLK, Ng GYF, Cheung RTH. Gait Retraining for the Reduction of Injury Occurrence in Novice Distance Runners: 1-Year Follow-up of a Randomized Controlled Trial. American Journal of Sports Medicine. 2018;46(2):388–395. https://doi.org/10.1177/0363546517736277

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Transparency

• Authorship: Roger Hilfiker
• AI assistance: the literature search and the draft were produced with Claude (Anthropic). Roger Hilfiker checked every statement, figure and source and revised the text.
• Created: 27 August 2026
• Last updated: 27 August 2026
• Sources: the 24 papers in the reference list. All DOIs were checked against the Crossref register.
• How the sources were found: searches of the Europe PMC database in August 2026 on gait retraining in running, step rate, foot strike, medial tibial stress syndrome, foot position in knee osteoarthritis, return to running after cruciate ligament reconstruction, and strength, balance, stepping and dual-task training in older age. Where this text says that no study exists on a question, it refers to that search.
• Conflict of interest: our practice offers physiotherapy, training supervision and fall prevention, and earns money from them. This text names a documented benefit for several building blocks and at the same time says where evidence is missing. That applies particularly to the drill collection as a whole.
• Funding: Physiotherapie Tschopp & Hilfiker, 3902 Glis. The article was produced with the practice's own resources.
• Next review: 27 August 2028. We also revise this article on an ongoing basis whenever new articles are added. That happens about every two months.