Barrett T, Ho KY, Rasavage J, Wilson M, Goo-Tam M, Trumbull T.

Implementation of 2D
Running Gait Analysis in Orthopedic Physical Therapy Clinics. IJSPT.
2023;V18(3):606-618. doi:10.26603/001c.74726

Original Research

Implementation of 2D Running Gait Analysis in Orthopedic

Physical Therapy Clinics
a
Tiffany Barrett1 , Kai-Yu Ho1 , Justin Rasavage1, Micah Wilson1, Melissa Goo-Tam1, Tristan Trumbull1
1 Department of Physical Therapy, University of Nevada, Las Vegas
Keywords: 2D motion analysis, runners, implementation, running assessment
https://doi.org/10.26603/001c.74726

International Journal of Sports Physical Therapy

Vol. V18, Issue 3, 2023

Background
Despite 2D motion analysis deemed valid and reliable in assessing gait deviations in
runners, current use of video-based motion analysis among orthopedic physical
therapists is not prevalent.

Purpose/Hypothesis
To investigate clinician-perceived effectiveness, adherence, and barriers to using a 2D
running gait analysis protocol for patients with running-related injuries.

Study Design
Survey

Methods
Thirty outpatient physical therapy clinics were contacted to assess interest in
participation. Participating therapists were trained on 2D running gait analysis protocol
and given a running gait checklist. The Reach, Effectiveness, Adoption, Implementation,
and Maintenance (RE-AIM) framework was used to assess the implementation process by
collecting a baseline survey at the beginning of the study, effectiveness and
implementation surveys at two months, and a maintenance survey at six months.

Results
Twelve of the 15 responding clinics met eligibility criteria, giving a Reach rate of 80%.
Twelve clinicians from 10 different clinics participated, giving an Adoption rate of 83%.
For Effectiveness, the majority of clinicians valued having a checklist, and reported the
protocol was easy to conduct, the methodology was reasonable and appropriate, and
patients saw the benefits of using the protocol. Assessing Implementation, 92% performed
all steps of the protocol on all appropriate runners. Average time spent conducting the
protocol was 32 minutes. With respect to Maintenance, 50% reported continuing to use
the protocol, while 50% answered they were not to continue use.

Conclusion
Clinicians expressed a perceived benefit of implementing a running gait analysis protocol
with common themes of ease of use, being a useful adjunct to evaluating a patient, and
increased satisfaction with treating injured runners. Potential barriers for not using the
protocol included not having an appropriate clinic setup, time constraints, and not
having adequate caseload.

a Corresponding Author:
Tiffany Barrett
4505 S. Maryland Pkwy, Las Vegas, NV 89154, USA
Email: tiffany.barrett@unlv.edu
Fax: 702-895-4883
Phone: 702-895-4883
 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

Level of Evidence
3b

INTRODUCTION METHODS
2D MOTION ANALYSIS METHODS
It has been reported that 19% - 79% of runners experience
running-related injuries, and up to 40 million Americans The physical therapists that participated in this study were
experience running injuries each year.1 Although running instructed to use the specific setup and procedures below.
has many benefits, such as reduced risks for cardiovascular CoachNow (Shotzoom Software LLC, Tempe, Arizona,
disease and cancer mortality,2 it is associated with various https://coachnow.io), a free, 2D motion analysis smart-
musculoskeletal injuries, including medial tibial stress syn- phone application that supports video recording and analy-
drome, Achilles tendinopathy, plantar fasciitis, and sis with slow motion playback and dynamic annotation was
patellofemoral pain.3 The risk factors associated with sus- used to analyze the videos collected from a smartphone.
taining running-related injuries include abnormal running A similar smartphone application (Coach’s Eye), which has
mechanics, prior running injury, higher weekly mileage, been retired, has been shown to be a valid and reliable tool
and increased frequency of running.1,4 Given that running for analyzing various running gait kinematics.12 Specifi-
in faulty forms are associated with musculoskeletal in- cally, Mousavi and colleagues showed excellent intra- and
juries,1 implementation of running gait analysis in ortho- inter-rater reliability with the use of Coach’s Eye during
pedic/sports physical therapy settings has been suggested treadmill running (ICCs ranged from 0.87-0.99). When
to help identify abnormal mechanics in runners and combat compared to 3D motion analysis, they reported fair to ex-
the occurrence of these injuries. cellent validity for measuring hip, knee, ankle, and foot
Two-dimensional (2D) motion analysis is an affordable, kinematics, with ICCs ranging from 0.51 to 0.79.12 The
time-efficient method for analyzing running mechanics in sagittal view was taken with the camera placed two meters
runners.5–7 For runners, 2D motion analysis is comparable from the side of the treadmill, while the posterior view
to 3D motion analysis in quantifying sagittal plane kine- was taken with the camera 1.5 meters from the back of the
matics of the hip, knee, and ankle during running.6 2D treadmill.12 For both views, the camera was one meter off
analysis has also been shown to provide reliable results the ground, horizontally secured into the tripod, and or-
for assessing running gait kinematics.1,8–10 Identification thogonally positioned relative to the plane of interest in or-
of gait events and common kinematic variables, including der to reduce skewing of angles during analysis.
rearfoot position, foot-strike pattern, tibial inclination an- Standardized patient setup included patients being
gle, knee flexion angle, knee separation, and forward trunk asked to wear running shorts, a tank top or sports bra for
lean, were found to be highly reproducible.1 Excellent in- females and no shirt for males in order to facilitate opti-
tra- and inter-tester reliability was demonstrated with con- mal marker placement and observation of key landmarks.
tralateral pelvic drop and hip adduction angles in the The markers used were round, 1-inch diameter, fluorescent
frontal plane,10 as well as with sagittal plane measures, re- 2D stickers placed at the C7 spinous process, posterior su-
gardless of clinician experience.9 A recent systematic re- perior iliac spines, greater trochanters, lateral knee joint
view concluded that 2D video analysis is a reliable method lines, knee joint center, lateral malleoli, midpoints of the
for assessing foot strike pattern and quantifying step rate.8 calf, superior and inferior portions of the heel shoe counter,
The information obtained from these 2D running gait and the fifth metatarsal heads (Figure 1).
analyses can be utilized by clinicians to inform their plan Patients were instructed to warm up on the treadmill
of care with the goal of improving a patient’s running me- at a self-selected speed for six to ten minutes at 0% in-
chanics to decrease their risk of injury.5 cline.4 After the warm-up period, two 25-second videos
Despite the benefits of using 2D motion analysis, current were recorded in succession for each view.
use of video-based motion analysis among orthopedic Once recording was complete, each video was uploaded
physical therapists is not prevalent: less than 50% of ortho- and analyzed with CoachNow. Analysis included viewing
pedic physical therapists use it in their routine caseload.11 the footage in slow motion, pausing and using a scroll bar
Therefore, there is a need to investigate the process and to identify precise gait events, and annotating still frame
effects of implementing 2D running gait analysis in clini- images to better visualize joint and body positions. Gait
cal physical therapy settings. Therefore, the purpose of this events to be identified were initial contact, defined as the
study was to investigate clinician-perceived effectiveness, first contact of the shoe on the treadmill belt, and mid-
adherence, and barriers of using a 2D running gait analysis stance, defined as the instance the swing knee was adjacent
protocol for patients with running-related injuries. An ad- to the stance knee.1 In addition, a running gait checklist
ditional aim of this study was to evaluate the value of im- that researchers adapted from the work of Pipkin et al.1 was
plementing 2D running gait analysis by examining the as- provided to assess the alignment during the initial contact
sociations between the plan of care, usefulness of routine of the sagittal plane and midstance of the frontal and sagit-
use, clinicians’ satisfaction, patient-perceived benefit, time tal planes (Table 1 and Appendix 1).
spent on the 2D motion analysis, and/or clinician perceived
usefulness for making treatment plan decisions.

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

Table 1. Running Gait Checklist.

Gait
Plane Variable Description Scoring Clinical significance
phase
-Excessive ipsilateral
-Increased trunk motion in either direction related to low
-Mild ipsilateral
Line from T1-S1 relative to true back pain
Trunk sidebend -Approximate (vertical)
vertical -Ipsilateral sidebend may occur in attempt to unload lateral
-Mild contralateral
hip of stance limb
-Excessive contralateral
-Appropriate (male= 3 degrees- 5
degrees; female= 4 degrees-7 Increased contralateral pelvic drop related to IT band
Lateral pelvic Line through posterior superior iliac
degrees) syndrome, anterior knee pain, lateral hip pain on stance
drop spines relative to true horizontal
-Mild limb
-Excessive contralateral
-Excessive lateral
-Mild lateral
Knee center Position of knee center relative to Both medial and lateral positions of knee related to
-Appropriate (mid-line)
position line connecting hip and ankle centers patellofemoral pain
-Mild medial
-Excessive medial
-Excessive narrow
-Mild narrow -Narrow suggestive of dynamic valgus
Distance between the medial aspect
Knee separation -Appropriate (slight separation) -Wide suggestive of dynamic varus
of knees
-Mild wide -Can be related to anterior knee and hip pain
Frontal Midstance -Excessive wide
-Excessive crossover
-Mild crossover
Foot-to-center of
Mediolateral distance of medial heel -Appropriate (medial shoe adjacent Crossover associated with medial tibial stress syndrome
mass (COM)
to vertical line from center of sacrum to line) and IT band syndrome
position
-Mild wide
-Excessive wide
-Excessive pronation
-Mild pronation -Increased pronation associated with anterior knee pain,
Angle created by midline of rearfoot
Rearfoot position -Appropriate Achilles tendinopathy, medial tibial stress syndrome
relative to midline of lower leg
-Mild supination -Increased supination associated with bone stress injuries
-Excessive supination
-Excessive abduction
-Mild abduction -Increased abduction related to Achilles tendinopathy and
Forefoot position Position of forefoot relative to heel -Appropriate plantar fasciopathy
-Mild adduction -Increased adduction related to bone stress fractures
-Excessive adduction
Heel-height Highest point of heel during swing -Left heel lower Asymmetrical heel height associated with unequal power
symmetry phase -Appropriate (symmetrical) generation from lower extremities

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

Gait
Plane Variable Description Scoring Clinical significance
phase
-Right heel lower
-Appropriate (20 degrees of flexion)
Ankle dorsiflexion Angle created by midline of lower leg
-Mild tibial inclination Increased inclination related to Achilles symptoms
angle relative to sole of foot
-Excessive tibial inclination
-Excessive decrease
Midstance -Mild decrease
Angle created by midline of thigh -Appropriate (approximately 40 Increased knee flexion associated with increased
Knee flexion angle
relative to midline of lower leg degrees of flexion) patellofemeral joint load and risk of anterior knee pain
-Mild increase
-Excessive increase
-Excessive decrease
-Mild decrease
Sagittal Midline of thigh relative to midline of -Appropriate (approximately 20 Associated with overstriding and risk of anterior knee pain
Knee flexion angle
lower leg degrees of flexion) and lateral hip pain
-Mild increase
-Excessive increase
Initial -Heel strike
contact Foot strike Sole of foot relative to running -Rearfoot strike Heel strike associated with anterior knee pain and lower leg
pattern surface at moment of contact -Midfoot strike injury
-Forefoot strike
-Appropriate (within 5 degrees of
Midline of lower leg relative to true vertical) Increased inclination associated with bone stress injuries of
Tibial inclination
vertical -Mild inclination lower leg
-Excessive inclination

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

cations in running analysis, and one physical therapist who

is a generalist. These experts provided a breadth of knowl-
edge related to video gait analysis and the practicality of
using video analysis in a clinic setting. They were asked to
assess the overall face and content validity by examining
the language used and relevance of each item in the ques-
tionnaire. Upon review of each survey question, each item
was deemed valid by all experts, and no changes were made
to the surveys.
The baseline survey gathered information about clinician
specialization, such as being a clinic or regional director,
prior running gait analysis training, current perceptions of
running gait analysis to assist with treatment of patients,
overall interest in the study, if they would be participating
in the study, and reasons for non-participation. The base-
line survey allowed the team to assess “Reach” and “Adop-
tion” rates of implementation.
For the effectiveness survey, a 5-point Likert scale was
used for the questions, where 1 represented a response of
Figure 1. Posterior and lateral marker placement over “not at all” and 5 a response of “very much”. Specifically,
specified anatomical landmarks. this survey asked for a rating of difficulty to conduct the
protocol, if the protocol set up was reasonable, if the run-
RE-AIM MODEL FOR ASSESSING THE IMPLEMENTATION ning gait checklist was useful for analyzing running gait
OF 2D RUNNING ANALYSIS patterns, if the protocol was worth routine use, if they felt
the patients saw the benefit of using this analysis in their
The process of implementing 2D running gait analysis evaluation, and if implementing the protocol affected their
into physical therapy clinics was assessed using the RE- overall satisfaction with treating running patients. Addi-
AIM (Reach, Effectiveness, Adoption, Implementation, and tional questions asked for a rating and an explanation for
Maintenance) framework.13–17 The RE-AIM model provides each answer. The questions included in this survey were as
a comprehensive evaluation framework to improve public follows: “Is the methodology reasonable and appropriate?
health and community-based interventions by facilitating Is the protocol helpful in making decisions in treatment
the translation of scientific advances into practice.18,19 plans? Does the protocol influence your plan of care?”
Specifically, Reach is defined as the extent to which imple- The implementation survey contained questions that as-
mentation reached the targeted population, measured by sessed the frequency in which the physical therapists per-
the percentage of outpatient orthopedic clinics deemed el- formed the protocol and to what extent they accurately fol-
igible compared to those approached that responded to the lowed the protocol. These included a numerical value for
authors’ inquiry. Adoption is defined as the extent to which number of times conducting the protocol in the last month
implementation is adopted in the clinical setting and by and average time in minutes conducting each individual
providers, measured by the percentage of orthopedic clinics running gait analysis. A yes or no answer was used for
willing to participate compared to those deemed eligible. questions asking if the amount of time spent performing
Effectiveness is defined as the impact of an intervention on the analysis was reasonable, if each runner warmed up for
important outcomes by analyzing how often therapists used the appropriate time, if all videos were taken for at least
information gained from running analysis, and perceived 25 seconds, if the CoachNow application was used to ana-
utility of using the protocol. Implementation is defined as lyze video footage for each runner, and if the running gait
the extent to which the intervention is implemented as in- checklist was used to interpret the findings for each runner.
tended by analyzing therapists’ adherence to the protocol. Additional yes and no questions with an explanation box if
Maintenance is defined as the sustainability of implementa- the participant answered “no” were used for the following
tion over time by analyzing therapists’ persistence to using questions: “Was the protocol performed on all appropriate
the protocol. patients? Were the stickers used on each landmark for each
runner? Were all videos taken from the specified setup cri-
SURVEYS TO ASSESS THE RE-AIM MODEL teria? Was CoachNow used as instructed? Was the running
gait checklist used as instructed?”
To assess the five dimensions of RE-AIM, the researchers The maintenance survey assessed how well the physical
created four surveys (i.e., baseline survey, effectiveness sur- therapists maintained the use of the 2D running analysis
vey, implementation survey, and maintenance survey) us- protocol. Questions asked in this survey were: “Have you
ing Qualtrics XM (Qualtrics Software Company, Provo, maintained use of the protocol? Have any adaptations been
Utah). All surveys were validated by a panel of five experts. made to the protocol? Will you continue to use the protocol
Face and content validity of the surveys were determined by in the future? Do you have any further input or suggestions
a panel of two physical therapy educators who specialize in about the protocol?”
orthopedics, two physical therapists with specialty certifi-

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

PROCEDURE population, and one reporting having an existing running

gait analysis protocol in place. Of the 12 eligible clinics, 10
The baseline survey was sent to 30 outpatient physical of them participated in the study, giving an adoption value
therapy clinics that are affiliated with the University of of 83%. The two clinics that chose not to participate indi-
Nevada, Las Vegas, to assess interest and eligibility in study cated time constraints and lack of cases to support effective
participation. To be eligible for the study, participating use of the protocol as reasons for non-participation. Ulti-
clinics did not have a current 2D running gait analysis pro- mately, 12 physical therapists from 10 different clinics par-
tocol in place, had to have a licensed physical therapist and ticipated in this study (Table 2). The age range of partici-
treadmill available within the facility, and had to be cur- pating physical therapists was 28-57 years old, with a mean
rently treating at least one patient with a running-related age of 41 years old. Eight of the 12 physical therapists were
injury. Once the participating clinics were identified, re- clinical or regional directors. Half of the therapists reported
searchers visited each clinic to train participating physical having prior standardized training with running gait analy-
therapists in performing the 2D running gait analysis us- sis, while the other half had no prior training (Table 2).
ing aforementioned methods. The physical therapists were Common reasons for participation included gaining
asked to perform this protocol at initial evaluations and knowledge and improving clinical skills in order to provide
re-evaluations on their appropriately designated patients, better treatment to runner patients and contributing to re-
defined as any patient with a running-related injury that search for the advancement of the physical therapy pro-
was willing and deemed safe by the evaluating therapist to fession. Five therapists’ initial perception of running gait
perform treadmill running for gait analysis. The therapists analysis was that “it can be useful if time permits and when
were also advised to use their findings to help inform their used with the appropriate population”. Four therapists ac-
treatment plan. knowledged that running gait analysis would be most ben-
The effectiveness and implementation surveys were sent eficial when used by trained and well-versed clinicians in
to all participating physical therapists after two months of running mechanics and that running analysis should not
participating in the study and contained questions pertain- be used in isolation, but rather as part of a full patient as-
ing to the protocol taught to therapists. The maintenance sessment. One therapist stated that running gait analysis
survey was completed four months after the effectiveness was useful for breaking down phases of gait, identifying
and implementation surveys were sent. All activities in this biomechanical faults and possible contributing factors to-
study were approved by the review board of University of wards injury, tracking progress, and when used in conjunc-
Nevada, Las Vegas (IRB 1712677-5). Informed consent was tion with patient education.
obtained for all subjects and participating facilities.
EFFECTIVENESS
STATISTICAL ANALYSIS
Table 3 details the effectiveness survey results regarding
The data collected from the four surveys were de-identified how the 12 included physical therapists ranked each survey
for confidentiality. Reach and Adoption were evaluated us- question. The four questions that received the highest rat-
ing descriptive statistics through the baseline survey. Ef- ing were “Is the protocol easy to conduct?”, “Is the method­
fectiveness and Implementation were assessed using de- ology reasonable and appropriate?” ,“Is the provided Running
scriptive statistics and qualitative analysis of information Gait Checklist useful for analyzing running gait patterns?”,
gathered from their respective surveys. Maintenance was and "Do the patients see the benefit of using this in their eval­
evaluated using descriptive and qualitative statistics from uation?", with a score ranging between 4.0 and 4.6. Two
the maintenance survey. For descriptive statistics, we re- questions received somewhat ambivalent/neutral ratings,
ported available mean, standard deviation, frequency (per- including “How useful was the protocol in helping you make
centage), and range. For quantitative analyses, Spearman’s decisions about your treatment plans?” and “Is the level of
rho correlation analysis (one-tailed, significance usefulness enough to make the protocol worthy of routine
level=0.05) was also conducted, where correlation strength use?”, with a score of 3.2 and 3.0, respectively. The remain-
(r) was adapted based off general guidelines and defined ing three questions scored intermediately between 3.7 and
as weak (r < 0.4), moderate (0.4 < r < 0.7), and strong (r > 3.8, including “Are the setup criteria reasonable?”, “Does us­
0.7) for this study.20 Quantitative data was analyzed in SPSS ing 2D running gait analysis influence your plan of care for
statistical package (SPSS version 27.0, IBM Corp., NY, USA), patients?”, and “How has implementation of the protocol af­
while qualitative data was assessed using ATLAS.ti. fected your overall satisfaction with the treatment you pro­
vide your running patients?”. A significant moderate positive
RESULTS correlation was found between the rating of the protocol’s
influence on plan of care and the rating of usefulness of
REACH AND ADOPTION
routine use (r=.516, p=.043). The rating of clinicians’ satis-
faction of implementing the 2D motion analysis in the pro-
Of the 30 clinics contacted, 15 clinics responded to the
vided treatment demonstrated positive moderate correla-
baseline survey. Twelve of these 15 clinics met the eligibil-
tions with the rating of the protocol’s influence on plan of
ity criteria for this study, giving a reach value of 80%. The
care (r=.509, p=.045), and with the rating of patient per-
remaining three clinics were not eligible to participate with
ceived benefit of using the protocol (r=.524, p=.040).
two of them stating they did not have the correct patient

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

Table 2. Demographics of eligible physical therapists, participating and non-participating.

Physical therapists participating

Therapist # Age Clinical position Prior training
1 28 Physical therapist Yes
2 28 Physical therapist Yes
3 32 Physical therapist No
4 32 Clinic director No
5 34 Clinic director Yes
6 36 Physical therapist Yes
7 41 Clinic director No
8 47 Clinic director Yes
9 47 Clinic director Yes
10 51 Regional director No
11 56 Clinic director No
12 57 Regional director No
Mean Age 41 -- --
% Therapists -- 67% director position 50%
Physical therapists declined participation
13 32 Clinic director No
14 31 Physical therapist Yes
Mean Age 31.5 -- --
% Therapists -- 50% director position 50%

Table 3. Effectiveness survey results.

Likert Likert Likert Likert Likert

Score Score Score Score Score
=1 =2 =3 =4 =5 Mean
(# of (# of (# of (# of (# of Likert
Survey Question PTs) PTs) PTs) PTs) PTs) Score
Is the protocol easy to conduct? 0 0 4 4 4 4.0
Are the set up criteria reasonable? 1 1 2 5 3 3.7
Is the methodology reasonable and appropriate? 0 0 1 5 6 4.4
Is the provided Running Gait Checklist useful for
analyzing running gait patterns? 0 0 0 5 7 4.6
How useful was the protocol in helping you make
decisions about your treatment plans? 0 2 7 2 1 3.2
Does using 2D running gait analysis influence your
plan of care for patients? 0 0 6 4 2 3.7
Is the level of usefulness enough to make the
protocol worthy of routine use? 0 4 4 4 0 3.0
Do the patients see the benefit of using this in their
evaluation? 0 0 2 8 2 4.0
How has implementation of the protocol affected
your overall satisfaction
with the treatment you provide your running
patients?
1= Greatly decreased satisfaction, 5= Greatly
increased satisfaction. 0 0 4 7 1 3.8

* Likert Score Rating: 1 = not at all, 5 = very much; unless otherwise specified

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

IMPLEMENTATION cians answering “yes” about why they continued to use the
protocol included two therapists reporting general interest
During the first month of implementation, six therapists in using the analysis to analyze patient’s running gait, two
conducted a single running analysis, two therapists con- therapists reporting the protocol being useful for patient
ducted two analyses, three therapists conducted three, and education, and one therapist feeling the protocol was quick
one therapist conducted four analyses, for a total of 23 to set up and easy to use. Reasons reported by the group an-
analyses (mean = 2 analyses). All therapists reported per- swering “no” to continuing protocol use included five ther-
forming the protocol on every appropriate runner with a apists reporting not having adequate case load to continue
running-related injury except for one therapist who was use, one therapist reporting time restraints, and one ther-
unable to conduct the protocol on one runner due to com- apist reporting clinic set up not allowing adequate use of
plications with setup in the clinic at the time. Therefore, protocol. Overall, only one out of 12 therapists (8%) re-
therapists performed the protocol on 23 of the 24 appro- ported making adaptations to the protocol. The adaptation
priate runners, a rate of 96%. The average time therapists reported was “did not take every measurement to shorten
spent performing each protocol was 32 minutes (range = the protocol to focus on specific patient goals”.
10-75 minutes), with 50% of the therapists spending be- When asked “Will you continue to use the protocol in the
tween 25-30 minutes on each running analysis. 75% of future?”, seven therapists answered “Probably yes”, four
the therapists felt the time spent conducting each analysis answered “Might or might not”, and one answered “Proba-
was reasonable, including those who spent 45 and 75 min- bly not”. Additional comments related to the protocol were:
utes on each analysis. The remaining three therapists who 1) the protocol would be useful in a cash pay setting rather
felt the time spent was unreasonable reported conduction than a busy outpatient setting, 2) the protocol is useful if
times ranging from 25-60 minutes. A significantly mod- not limited by time restraints, 3) having more appropriate
erately positive correlation was found between average patient populations would allow for more use, and 4) using
amount of time spent conducting protocol and the rating the stickers can be cumbersome to put on and have limita-
of clinician perceived usefulness for making treatment plan tions in their use.
decisions (r=.663, p=.009).
As shown in Table 4, 83% of therapists reported placing
DISCUSSION
markers on every designated landmark for each runner. Of
the remaining two therapists, one reported placing markers
Previous research has shown that more than 50% of sur-
for the frontal, but not sagittal view as their clinic setup did
veyed orthopedic physical therapists do not use video-
not allow them to obtain a sagittal view. Another therapist
based motion analysis in clinical practice.10,11 To under-
reported not needing markers at all. The majority of run-
stand the actual implementation of 2D running analysis
ners who had a running gait analysis performed, warmed
and barriers of implementation in clinical physical therapy
up for the designated time of 6-10 minutes, an adherence
setting, we aimed to examine the clinician-perceived no-
rate of 96%. Therapists were asked whether all videos were
tions of implementing a running gait analysis protocol into
taken from the specified distance, height and angles pro-
their practice via a RE-AIM model.
vided in the protocol, eight therapists (67%) answered yes.
The RE-AIM framework used in this study allowed us to
The four therapists who answered “no” gave responses re-
understand the details of the implementation process. The
lated to setup and time efficiency as reasons for making
“Reach” and “Adoption” rates in the beginning of this study
modifications. Specific issues with setup involved clinic lay-
were 80% and 83%, respectively, suggesting that we were
out not allowing for a sagittal view, treadmill handlebars
able to reach and initiate the adoption of the 2D running
obstructing the sagittal view, and differences in magnifica-
gait analysis in the majority of outpatient orthopedic clin-
tion between devices. 92% of therapists reported recording
ics. However, as 15 clinics did not respond to the proviced
all videos for at least 25 seconds, and 100% of therapists
survey, the reach and adoption rates observed in this study
used either the Coach’s Eye application or CoachNow appli-
may have been different if those clinics responded to the
cation to analyze video footage for each runner. Eleven of
baseline survey.
the 12 therapists used the applications as instructed while
With respect to the effectiveness of implementing the
one therapist did not, and instead used the application’s
2D running analyses, the majority of the clinicians that
line tool to draw a plumbline from which they could em-
participated in this study valued having a protocol with a
phasize angles, alignment, and contact points. All thera-
checklist in which they could quantitatively analyze their
pists used the running gait checklist to interpret findings
patient’s running gait pattern with a reported mean score
for each runner, with 11 of 12 therapists using the checklist
of 4.6 on a five-point Likert scale. Additionally, most ther-
in the manner that was instructed. One therapist reported
apists reported that the protocol was easy to conduct, the
skipping through some of the checklist for efficiency.
methodology was reasonable and appropriate, and the pa-
tients saw the benefits of using the protocol in their evalu-
MAINTENANCE
ation. However, the questions about the level of usefulness
Of the 12 clinicians completing the study (Table 5), six for making the protocol worthy of routine use and for help-
therapists (50%) reported continuing to use the running ing clinicians make decisions about the treatment plan re-
gait analysis protocol, while six therapists (50%) answered ceived neutral rating (around 3.0). This may be attributed
“no” to continuing use. Comments from the group of clini- to time constraint and patient’s competing needs in an out-

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

Table 4. Implementation survey results.

Survey Question Yes No Compliance

(# of PTs) (# of PTs) Percentage
Was the protocol performed on all appropriate runners with running-related injuries? 11 1 91.7%
Is the amount of time spent on each running gait analysis reasonable? 9 3 --------
Were markers placed on every landmark for each runner? 10 2 83.3%
Did each runner warm up for the appropriate amount of time? 11 1 91.7%
Were all videos taken from the specified distance, height, and angles provided in the 8 4 66.7%
protocol?
Were all videos taken for at least 25 seconds? 11 1 91.7%
Was either the Coach’s Eye or CoachNow application used to analyze video footage for 12 0 100%
each runner?
If yes, was it used as instructed? 11 1 91.7%
(as follow-up to the above question)
Was the Running Gait Checklist used to interpret the findings for each runner? 11 1 91.7%
If yes, was it used as instructed? 11 0 100
(as follow-up to the above question)

Table 5. Maintenance survey results.

Survey Question Yes No

Have you maintained the use of the 2D running gait 50% 50%
analysis protocol?
Since the end of the study, have any adaptations been 17% 83%
made to the protocol in order to accommodate the
specific needs of your clinic?
Survey Question Definitely Probably Might or Probably Definitely
not not might not yes yes
Will you continue to use the protocol in the future? 0% 8% 33% 58% 0%

patient setting. Of the clinicians who chose to elaborate on It is also important to acknowledge that some clinicians
why they felt that the protocol was or was not worthy of who might attempt to implement this protocol may not
routine use, all of them stated that time was the signifi- have access to video technology or access to the application
cant factor in why it might not be. Interestingly, a moder- used to analyze running gait in this study, which could limit
ately positive correlation was found between the amount of their ability to conduct this analysis. Although all clinics
time spent conducting the protocol and clinician perceived were deemed eligible prior to implementation, change in
usefulness in developing a treatment plan, suggesting that clinic setup or in clinician video devices could have created
the increased amount of time taken to properly conduct the barriers to using the running analysis. Having a consistent
protocol could benefit therapists’ in developing individual- manner to record videos and perform analysis is essential,
ized treatments for their patients. One possible strategy to meaning clinicians will need to assess their own setups to
alleviate the time required for administering the 2D mo- decide if they are able to perform the analysis.
tion analysis is to have other clinic personnel assist with When asked if the protocol influenced their plan of care,
the camera setup and marker placements to shorten the clinicians most frequently stated that it helped to provide
amount of time taken to perform the entire protocol. patient education and to design treatment plans based on
One potential barrier to implementing this protocol ex- their patient’s gait abnormalities. Importantly, associations
pressed by clinicians was not having appropriate clinic were found between the protocol’s influence on plan of care
setup to accommodate performing this protocol. One clini- and usefulness of routine use, and between clinicians’ sat-
cian stated that their clinic space did not allow for sagittal isfaction of implementing the 2D motion analysis and the
views, one reported having a treadmill with handlebars that protocol’s influence on plan of care/patient perceived bene-
obstructed the field of view, and one clinician stated that fit. Multiple clinicians also expressed the importance of this
different [video recording] devices display different magni- protocol being used in conjunction with other examination
fication settings, which may require clinicians to adjust the strategies, rather than using this protocol as a standalone
distance to the treadmill that videos are taken from in or- assessment. Further research will need to be conducted to
der to get all markers within view. assess what strategies would best be incorporated with per-
forming a running gait analysis. Since visual feedback is al-

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

ready a common use of video-based motion analysis among perspectives were not assessed. This study focused solely
clinicians that use cameras to analyze their patient’s move- on the clinicians’ views of implementing 2D running gait
ment,11 the integration of patient education along with vi- analysis, but evaluating patient outcomes could provide
sual feedback when using this protocol has the potential to useful information and should be considered for future re-
be a significant benefit of using this 2D running gait analy- search. A third limitation in the current study was that
sis. many of the therapists had high caseloads. Time con-
Half of the clinicians involved in this study reported not straints and inadequate patient population were commonly
continuing protocol use after the six-month maintenance reported barriers in this study; thus, the results could po-
survey. This rate is similar to that of a larger-scale sur- tentially be different if the study was done with different
vey study that assessed the prevalence of using 2D motion clinician populations.
analysis in orthopedic physical therapy clinics.11 However,
the majority of clinicians reported that they would or prob- CONCLUSION
ably would use the protocol in the future. This shows that
even though clinicians did not remain consistent after six The results of this study provide evidence that 2D running
months, they are open to using it again when needed. Clini- gait analysis is a potentially valuable intervention that can
cians expressed that the main hinderances to continued use be utilized by outpatient physical therapy clinicians to as-
are not having a sufficient patient caseload to continue use sist with evaluating injured running patients and devising
and time restraints due to their clinic setting. No clinicians treatment plans. Clinicians that participated in this study
reported discontinuing use of the protocol due to any spe- expressed a perceived benefit of implementing a running
cific protocol reasons or feeling that the protocol was not gait analysis protocol with common themes of ease of use,
useful, leading the researchers of this study to believe that being a useful adjunct to evaluating a patient, and in-
a much higher retention rate would have been plausible if creased satisfaction with treating injured runners. Potential
clinicians worked with more patients that were runners or barriers presented in this study included clinicians not hav-
had more time to evaluate each patient. Also, only minimal ing appropriate clinic setup, being restricted by time con-
reports of changes or suggestions were made by clinicians straints, and not having adequate patient populations. The
about the protocol, demonstrating that the protocol itself use of a 2D running gait analysis protocol in outpatient
may not be the reason for the low retention rate. physical therapy settings may be improved by eliminating
Lastly, while many clinicians stated that the protocol the barriers identified in this study.
was useful in designing their treatment plans, it is unclear
if the change in treatment resulted in improved function
as patient outcomes were not assessed. Nevertheless, these
results suggest using this protocol in a clinical setting with DISCLOSURES
an appropriate patient population, sufficient amount of
time to evaluate each patient, and proper clinic set-up may The authors report no conflicts of interest.
provide clinicians an effective tool to help guide patient
evaluations and design treatment plans. Submitted: December 22, 2022 CDT, Accepted: March 26, 2023
The study has several limitations. First, given that this CDT
study was only conducted in the Las Vegas area, the find-
ings may not be generalizable to other areas. Another lim-
itation of the current study is that patient outcomes or

This is an open-access article distributed under the terms of the Creative Commons Attribution 4.0 International License
(CCBY-NC-4.0). View this license’s legal deed at https://creativecommons.org/licenses/by-nc/4.0 and legal code at https://cre-
ativecommons.org/licenses/by-nc/4.0/legalcode for more information.

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

REFERENCES

1. Pipkin A, Kotecki K, Hetzel S, Heiderscheit B. 11. Hensley CP, Millican D, Hamilton N, Yang A, Lee
Reliability of a qualitative video analysis for running. J, Chang AH. Video-based motion analysis use: a
J Orthop Sports Phys Ther. 2016;46(7):556-561. doi:1 national survey of orthopedic physical therapists.
0.2519/jospt.2016.6280 Phys Ther. 2020;100(10):1759-1770. doi:10.1093/ptj/p
zaa125
2. Pedisic Z, Shrestha N, Kovalchik S, et al. Is running
associated with a lower risk of all-cause, 12. Mousavi SH, Hijmans JM, Moeini F, et al. Validity
cardiovascular and cancer mortality, and is the more and reliability of a smartphone motion analysis app
the better? A systematic review and meta-analysis. Br for lower limb kinematics during treadmill running.
J Sports Med. 2020;54(15):898-905. doi:10.1136/bjspo Phys Ther Sport. 2020;43:27-35. doi:10.1016/j.ptsp.20
rts-2018-100493 20.02.003

3. Lopes AD, Hespanhol LC Jr, Yeung SS, Costa LOP. 13. McCreight MS, Rabin BA, Glasgow RE, et al. Using
What are the main running-related musculoskeletal the Practical, Robust Implementation and
injuries? A systematic review. Sports Med. Sustainability Model (PRISM) to qualitatively assess
2012;42(10):891-905. doi:10.1007/bf03262301 multilevel contextual factors to help plan,
implement, evaluate, and disseminate health services
4. Souza RB. An evidence-based videotaped running programs. Transl Behav Med. 2019;9(6):1002-1011. do
biomechanics analysis. Phys Med Rehabil Clin N Am. i:10.1093/tbm/ibz085
2016;27(1):217-236. doi:10.1016/j.pmr.2015.08.006
14. Magel J, Hansen P, Meier W, et al.
5. Dingenen B, Staes F, Vanelderen R, et al. Implementation of an alternative pathway for
Subclassification of recreational runners with a patients seeking care for low back pain: a prospective
running-related injury based on running kinematics observational cohort study. Phys Ther.
evaluated with marker-based two-dimensional video 2018;98(12):1000-1009. doi:10.1093/ptj/pzy105
analysis. Phys Ther Sport. 2020;44:99-106. doi:10.101
6/j.ptsp.2020.04.032 15. Kwan BM, McGinnes HL, Ory MG, Estabrooks PA,
Waxmonsky JA, Glasgow RE. RE-AIM in the real
6. Schurr SA, Marshall AN, Resch JE, Saliba SA. Two- world: Use of the RE-AIM framework for program
dimensional video analysis is comparable to 3D planning and evaluation in clinical and community
motion capture in lower extremity movement settings. Front Public Health. 2019;7:345. doi:10.3389/
assessment. Int J Sports Phys Ther. fpubh.2019.00345
2017;12(2):163-172.
16. Holtrop JS, Rabin BA, Glasgow RE. Qualitative
7. Johnston W, Heiderscheit B. Mobile technology in approaches to use of the RE-AIM framework:
running science and medicine: are we ready? J Orthop rationale and methods. BMC Health Serv Res.
Sports Phys Ther. 2019;49(3):122-125. doi:10.2519/jos 2018;18(1):177. doi:10.1186/s12913-018-2938-8
pt.2019.0604
17. Feldstein AC, Glasgow RE. A practical, robust
8. de Oliveira FCL, Fredette A, Echeverría SO, Batcho implementation and sustainability model (PRISM) for
CS, Roy JS. Validity and reliability of 2-Dimensional integrating research findings into practice. Jt Comm J
video-based assessment to analyze foot strike pattern Qual Patient Saf. 2008;34(4):228-243. doi:10.1016/s15
and step rate during running: a systematic review. 53-7250(08)34030-6
Sports Health. 2019;11(5):409-415. doi:10.1177/19417
38119844795 18. Glasgow RE, Harden SM, Gaglio B, et al. RE-AIM
planning and evaluation framework: adapting to new
9. Reinking MF, Dugan L, Ripple N, et al. Reliability science and practice with a 20-year review. Front
of two-dimensional video-based running gait Public Health. 2019;7:64. doi:10.3389/fpubh.2019.000
analysis. Int J Sports Phys Ther. 2018;13(3):453-461. d 64
oi:10.26603/ijspt20180453
19. Glasgow RE, Vogt TM, Boles SM. Evaluating the
10. Dingenen B, Staes FF, Santermans L, et al. Are public health impact of health promotion
two-dimensional measured frontal plane angles interventions: the RE-AIM framework. Am J Public
related to three-dimensional measured kinematic Health. 1999;89(9):1322-1327. doi:10.2105/ajph.8
profiles during running? Phys Ther Sport. 9.9.1322
2018;29:84-92. doi:10.1016/j.ptsp.2017.02.001

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

20. Portney L, Watkins M. Foundations of Clinical

Research: Applications to Practice. 3rd ed. F.A. Davis
Company; 2015.

International Journal of Sports Physical Therapy

 Implementation of 2D Running Gait Analysis in Orthopedic Physical Therapy Clinics

SUPPLEMENTARY MATERIALS

Appendix
Download: https://ijspt.scholasticahq.com/article/74726-implementation-of-2d-running-gait-analysis-in-orthopedic-
physical-therapy-clinics/attachment/157343.pdf

International Journal of Sports Physical Therapy