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Dx & Rx of running injuries:

Practical aspects

Twitter: @JFEsculier

Jean-Francois Esculier PT, PhD

Postdoctoral fellow, University of British Columbia

Vice-President, Director R&D, The Running Clinic

PT, Allan McGavin Sports Medicine Clinic (UBC)

Plan

• Practice and discussion

• Practice and discussion!

• Practice and discussion!!

• Practice and discussion!!!

No stats, no strong science, no manual

and not so much theory...

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Protectionvs

Adaptation

@JFEsculier

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ITBSITBS

Stress Fx (distal)Stress Fx (distal)

PFPPFP

Plantar FasciapathyPlantar Fasciapathy

LBPLBP

MTSS (Shin Splints)MTSS (Shin Splints)

Tendinopathy (A, P, ...)Tendinopathy (A, P, ...)

Stress Fx (proximal)Stress Fx (proximal)

Tendinopathy (IP)Tendinopathy (IP)

Muscle StrainMuscle Strain

Range Repetition

Load

Pes AnserinusPes Anserinus

Injury typesdepending on the stress applied

…increase load on

Maximalist running shoes

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…decrease load on

Maximalist running shoes

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KISS

90%

5%

3%

2%

DxTx

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Therapeutic relationship

Voltaire

The art of medicine

consists in amusing the

patient while nature cures

the disease.

Scanning the Lower Extremity

• Flexions: Squat test

• Extensions: Long strike on step

• Rotations: Body torque

Assess quality and quantity of movement at

each lower extremity joint:

Lower back-hip, Knee, Ankle-foot-hallux

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Functional ROM

• Flexion: Squat test

Functional ROM

• Extension: Long strike on step

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Functional ROM

• Rotations: Body torque

Hip

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Trochanteric bursitis

Dx:

- Lateral hip pain.

- Pain on palpation and swelling just

proximal to greater trochanter.

- Manual compression test +.

DDx : Femur, ilium, sacrum, lumbar, Coxo-femoral, sacro-iliac,

labrum, TFL-BIT, gluteus medius/minimus, gluteus maximus,

hamstrings, adductors, quadriceps, hip flexors, Lx radiculopathy,

lateral cutaneous nerve.

Proximal ITB syndrome

Dx:

- Lateral hip pain.

- Painful repeated movements.

- Pain on palpation proximal ITB (?).

- Compression stress test + (friction with

repeated hip flex/ext while in adduction,

weight bearing).

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Insertional ITB fasciapathy

Dx:

- Pain localized specifically at iliac tubercle

provoked by repeated pelvic drop

movements.

- Pain on palpation of iliac tubercle.

- Painful stretch of ITB in standing (weight

bearing hip adduction).

Gluteus medius tendinopathy

Dx:

- Pain superior to greater trochanter.

- Painful resisted hip abduction (stress at

different angles)

- Pain on palpation, superior to greater

trochanter.

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Hip flexors tendinopathy

Dx:

- Pain in groin / anterior hip.

- Painful resisted hip flexion (test at different

angles). Differentiate from abdominal

muscles.

- Painful palpation anterior aspect of hip

(ASIS, AIIS, fascia).

Sacro-iliac joint Robinson 2007 Laslett 2003, 2008

Dx:

- Posterior pain, localized around PSIS (?)

- Pain provocation tests: FABER,

Compression, Distraction, Prone internal

rotation (ipsi or contralateral), Thigh thrust

(Minimum 3/5 positive tests and no centralization or directional preference)

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Femoro-acetabular

impingementDx:

- Deep groin pain

- FADIR test + (anatomical?)

- Compensatory toeing-out

Femoro-acetabular

impingementDx:

- Deep groin pain

- FADIR test + (anatomical?)

- Compensatory toeing-out

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Labral tearSR 2008, Leibold

Dx:

- Deep groin pain.

- Perceived "clunk" (?)

- If FADIR, FABER, Fitzgerald and Thigh

thrust negative, labral tear is excluded

Currently, research has produced no tests with sufficient specificity to help confidently rule in a

diagnosis of hip labral lesion. Current best evidence indicates that a negative finding for the flexion-

adduction-internal rotation test, the flexion-internal rotation test, the impingement provocation test, the

flexion-adduction-axial compression test, the Fitzgerald test, or a combination of these tests provides

the clinician with the greatest evidence-based confidence that a hip labral lesion is absent.

Coxo-femoral capsular

patternDx:

- Restricted ROM and pain at end-range (?)

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Femoral neck stress fracture

Dx:

- Deep pain, not localized on palpation

- Inconsistency in pain location during

resisted hip movements (pain not

suggestive of muscle involvement)

- Fulcrum test + (sitting at edge of table)

Proximal hamstrings

tendinopathyDx:

- Pain localized at ischial tuberosity (inferior

buttock pain).

- Painful activities: bending forward,

squatting, upstairs, prolonged sitting.

- Painful resisted movements, worse in

stretched/compression positions.

- Painful stretch/compression (SLR).

- Painful palpation.

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Meralgia Paresthetica

Dx:

- Neural-type pain antero-lateral aspect of

the thigh (tingling, pins and needles,

burning).

- Decreased sensitivity to light touch.

- Neural tension tests + (PKB / HADD).

- Tinel's sign + (?)

T : � speed, avoid uphill and plyometrics

P : “doughnut” cushion for sitting (avoid compression)

E : Eccentric strengthening for hamstrings,

stretching (PRN)

MSQ… 180, minimalist

Proximal hamstring tendinopathy

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Kn

ee

Ottawa knee rules

Bone tenderness patella Bone tenderness fubular head

Inability to bear weight both immediately after the injury and in the emergency department

Inability to flex the knee more than 900

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Patellofemoral pain2013-Lankhorst, 2013-Osorio, 2013-Toumi, 2012-Dolak, 2012-Jessee, 2009(SR)-Fagan, 2005-Aminaka, 2003-D’hondt

Dx:

- Anterior knee pain, pain with squatting.

- 3 painful activities among: running,

walking, kneeling, upstairs/downstairs,

prolonged sitting

- Clark compression test + (?).

- Painful resisted knee extension 20-45°.DDx : tibial plateau, tibial tuberosity, patella, femoral condyles,

bursae, hoffa fat pad, synovial plica, menisci, patellar tendon,

quadriceps tendon, VMO, tibialis anterior, lateral retinaculum,

saphenous nerv (infra-patellar branch), lateral/medial/intermediate

cutaneous nerves of thigh

Prepatellar bursitis

Dx:

- Pain localized just proximal to patella with

edema (not always apparent).

- Painful palpation.

- Painful passive end-range knee flexion.

- Cutaneous tension/release test +.

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Fat pad syndrome (Hoffa)

Dx:

- Infra-patellar pain.

- Painful palpation medial and/or lateral to

patellar tendon.

- Painful end-range passive extension

- Hoffa test +.

Patellar tendinopathy

Dx:

- Infrapatellar pain, localized on patellar

tendon.

- Painful activities: deep squats, kneeling.

- Painful palpation of patellar apex.

- Painful resisted knee extension 90-120°.

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Quadriceps tendinopathy

Dx:

- Suprapatellar pain.

- Pain on squatting.

- Painful palpation of quadriceps

attachment on patella (superior).

- Painful resisted knee extension 90-120°.

Pediatric apophysitis

Osgood Schlatter

Sinding-Larsen-Johansson

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Lateral retinaculatis

Dx:

- Pain on lateral aspect of patella during

flexion/extension movements at the knee.

- Pain on palpation lateral border of patella.

- Pseudo-Ober test + (selective tension of

lateral retinaculum by flexing knee on

Ext/Add hip)

Pes anserinus tendinopathy

Dx:

- Pain localized at pes anserinus (bursitis more

than tendinitis? Extension of intra-articular edema?).

- Painful repeated movements.

- Resisted movements rarely painful

(gracilis, sartorius, semitendinosus).

- Painful palpation, edema.

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Iliotibial band syndrome2013-Louw, 2012-Meardon, 2005-Hoch, 1979-Noble

Dx:

- Non-traumatic lateral knee pain.

- Painful repeated flex/ext (running).

- Painful palpation of lateral femoral

epicondyle.

- Noble test + (friction around 30° flexion).

Superior tibiofibular joint

Dx:

- Lateral knee pain.

- Painful palpation of superior tibiofibular

joint.

- Painful passive joint mobilisation (90° of

knee flexion with relaxed biceps femoris).

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Biceps femoris tendinopathy

Dx:

- Pain at posterolateral aspect of knee

during activities involving knee flexion.

- Pain on palpation of tendon (squeeze).

- Painful resisted knee flexion + external

rotation while at 90° of flexion.

- Straight Leg Raise (SLR) stretch.

Tendinopathy of popliteus

Dx:

- Lateral knee pain.

- Painful palpation of lateral tibiofemoral

joint line.

- Garrick test + (resisted knee flexion + IR

while at 20° of knee flexion).

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Common fibular neuropathy

Dx:

- Neural-type lateral knee pain (tingling,

numbness, burning).

- Painful palpation along path of common

fibular nerve.

- Decreased nerve conductivity?

- Neural tension test + (SLR, ankle

inversion + plantarflexion).

Sciatica?

Dx:

- Posterior knee pain

- SLR / Slump test +.

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Baker's cyst

Patellofemoral pain2015-van der Heijden(CR), 2015-Lack(SR), 2015-Santos(SR), 2015-Alba(SR), 2013-Lankhorst, 2013-Osorio, 2013-

Toumi, 2012-Dolak, 2012-Jessee, 2009(SR)-Fagan, 2005-Aminaka, 2003-D’hondt

T: � volume, speed, avoid downhill

gait retraining

P: Neuro-proprioceptive taping2015-Chang (SR), 2015-Leibbrandt (SR), 2014-Barton (SR)

E: Hip strengthening, Quadriceps

strengthening, Core strengthening,

Lower limb control

MSQ… 180, minimalist

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Patellofemoral pain2016-Crossley

Patellofemoral pain

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Weeks

1-2

Weeks 3

-4

Patellofemoral painExercises

@JFEsculier

Weeks

5-6

Weeks 7

-8

Patellofemoral painExercises

@JFEsculier

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T: � volume, avoid downhill, maintain

intensity, 1’walk, avoid straight line

P: Neuro-proprioceptive taping, massage ,

NSAID (per os, gel, corticosteroids)

E: Hip strengthening (Abductors)

Step down (increase demand on control / increase loading)

Iliotibial band syndrome2013-Louw, 2012-Meardon, 2005-Hoch, 1979-Noble

MSQ… 180, minimalist

T: � intensity, volume, avoid downhill

P: “Levy” strap

E: Isometric knee extension at 45°of

knee flexion; Concentric/Eccentric;

Eccentric strengthening of quadriceps

Patellar Tendinopathy

MSQ… 180, minimalist

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Fo

ot

Ottawa ankle rules

Bone tenderness at posterior edge (distal 6 cm) or tip of lateral malleolus

Bone tenderness at posterior edge (distal 6 cm) or tip of medial malleolus

Inability to bear weight both immediately after the injury and in the emergency department

Bone tenderness at base of fifth metatarsal

Bone tenderness at navicular bone

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MTSS (shin splints)2013-Liem, 2012-Dubois, 2008-Graig, 2006-Raasch, 2005CR-Rome, 2005-Hoch, 2002-Thacker

Dx:

- Pain at posteromedial tibial crest.

- Painful palpation of medial tibial diaphysis

(large zone).

MTSS (stress fracture) 2013-Liem, 2008-Graig, 2006-Raasch, 2005CR-Rome, 2005-Hoch, 2002-Thacker

Dx:

- Pain at posteromedial tibial crest.

- Local edema.

- Painful localized palpation of the medial

tibial crest.

- Fulcrum test +.

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MTSS (stress fracture)2014-Warden

Compartment syndrome

• Pain during activity.

• Increases in intracompartmentalpressure can potentially cause neural or vascularsymptoms.

Increases in muscle volume (+25%) during activity is

greater than the compartment's capacity.

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T: � speed, avoid hills and plyometrics

P: Taping (circular or butterfly)

Desensitization (myofascial release)

US for stress fracture (0.05w/cm2, 20’, 4x/week)

E: Calf stretch (PRN)

Heel drop program (adaptation)

MTSS & Stress fracture2013-Liem, 2012-Dubois, 2008-Graig, 2006-Raasch, 2005CR-Rome, 2005-Hoch, 2002-Thacker

MSQ… 180, minimalist

Chronic exertional

compartment syndrome2013-Waterman

Dx:

- Pain of potentially severe intensity at the

anterior part of the leg (lateral of tibia)

after several minutes of exercise.

- Painful activity: running with a significant

rearfoot strike.

- No clinical signs aside from pain during

effort.

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T: Avoid downhill

P: 180, forefoot, low drop shoes

E: Skipping

Ant. compartment syndrome2015-Helmhout, 2013-Waterman, 2012-Diebal

180, minimalist

Achilles tendinopathy

Dx:

- Pain located at Achilles tendon.

- Pain during hopping, jumping, running.

- Royal London Hospital test +

- Squeeze test palpation.*Differentiation between mid-portion and insertional

tendinopathy will help focusing treatment aproach.

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Retrocalcaneal bursitis

Dx:

- Pain located anterior to Achilles tendon.

- Pain during walking with increased ankle

dorsiflexion (uphill).

- Negative Royal London Hospital test.

- Painful palpation just proximal to

calcaneus.

- Potential edema.

Haglund's syndrome

Bony exostosis caused by repeated traction of Achilles on calcaneus. Treat just like persistent insertional Achilles tendinopathy.

*Avoid tendon compression component during early stages of rehab*

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Calcification

Tendon condition sometimes associated withpersistent tendinopathy. Treat like persistent Achilles tendinopathy. Shock wave therapycould be indicated if longstandingsymptoms.

Pediatric apophysitis

Sever's disease

Appropriate load management to allowrecovery and decreased symptoms / improved function.

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T: � speed, avoid uphill

P: Neuro-proprioceptive taping (?)

Desensitization (calf massage)

E: Isometric program with plantarflexed

ankle; Heel drop program (adaptation)

Calf stretch (PRN; avoid if insertional tendinopathy!!!)

Achilles Tendinopathy

MSQ… 180

T: � speed, avoid hills

P: Neuro-proprioceptive taping (?)

Plantar orthoses

E: Heel drops with elastic pulling medially (adaptation)

Strengthening foot intrinsics (dynamic support)

Calf stretch (PRN)

Tib post Tendinopathy

MSQ… 180, minimalist

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Plantar fasciapathy2008-Neufeld, 2003-DiGiovanni

Dx:

- Pain located anteromedial to calcaneus

- Morning stiffness.

- Pain with toe walking, jumping, hopping,

running.

- Painful palpation at proximal insertion of

plantar fascia, best without tension in

plantar fascia by flexing hallux.

Heel spur

• Bony exostosis at proximal insertion of plantar fascia secondary to repeatedtractions.

Found in 10 - 30 % of

asymptomatic people;

Represents 50 - 75 % of heel pain.

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Fat pad syndrome (foot)

2012-Dragoo

Dx:

- Pain inferior to calcaneus (central or

sides).

- Pain during heel walking.

- Painful palpation central and inferior of

calcaneus.

(periostitis inferior of calcaneus?)

T: � speed, avoid uphill and plyometrics

P: Neuro-proprioceptive taping

Orthoses (?)

Desensitization (massage)

E: Strengthening foot intrinsics (dynamic support)

Heel drop program (adaptation)

Calf stretch (PRN)

Plantar Fasciapathy2015-Rathleff, 2008-Neufeld, 2003-DiGiovanni

MSQ… 180

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T: � downhill

P: 180, forefoot,

Taping, gel pad (?), plantar orthoses

Shoes with lower drop

E: Heel drop program (adaptation)

Fat pad syndrome (heel)

2012-Dragoo

MSQ… 180

Metatarsalgia

Dx:

- Pain located on the plantar aspect of

metatarsal heads.

- Pain during toe walking, jumping, hopping.

- Painful palpation of plantar aspect of

metatarsal heads.

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T: � speed, avoid uphill and plyometrics

P: Metatarsal support, cushioned insole,

plantar orthoses

E: Strengthening foot intrinsics

Metatarsalgia

MSQ… 180

Metatarsal stress fracture

Dx:

- Pain located on dorsal aspect of foot.

- Local edema.

- Sharp pain on palpation of metatarsal

diaphysis.

- Fulcrum test +.

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T: � speed, avoid uphill and plyometrics

P: Taping, rigid sole, high drop shoes

E: Strengthening foot intrinsics

Metatarsal stress fracture

MSQ

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