Robert P. Wilder, MD, FACSMChair, Physical Medicine & Rehabilitation
The University of VirginiaMedical Director, The Runner’s Clinic at UVA
Team Physician, Ragged Mountain Racing
Common Running Injuries
Objectives
• Identify common contributors to running injuries
• Describe treatment for heel pain, stress fractures, and patellofemoral pain syndrome
• Understand the importance of proper mechanics in managing injury
• Outline criteria for running while treating injury
Epidemiology of Running Injuries
30 million active runners70% all runners sustain significant injury
40% knee15% each: shin, achilles, hip/groin10% foot and ankle5% spine
25% recreational5% elite
Epidemiology of Running Injuries
4% bit by dogs0.3% hit by bicycles0.6% hit by cars7% hit by thrown objects
Principle of Transition“Culprits & Victims”
Intrinsic Abnormalities
MalalignmentMuscle imbalanceInflexibilityMuscle weaknessInstability
Extrinsic Abnormalities
Training errorsEquipmentEnvironmentTechniqueSport-imposed deficiencies
Examination of the Injured Runner
HistoryBiomechanical assessmentSite-specific examDynamic examShoe examAncillary testing
radiologicelectrodiagnosticcompartment testing
History• Prior injury history• Team/Club• Identify transitions• MPW (20, 40)• Long run (< 1/3 weekly total)• Intensity• Surface (? Muscle tuning)• Shoes/orthotics (350-400 miles)• Cross Training• Goals• Life Stressors/fatigue• Females: eat d/o, menstrual irreg, osteopenia
Physical Examination
• Biomechanical assessment• Site specific examination• Dynamic examination• Ancillary testing• Shoe examination
Functional Screening
• Single Leg Stance• Single Leg Squat• Bilateral Squat• FHB isolation• Step-down Test• STAR Excursion Test• Swing Test
Functional Screening
Single Leg Stance
Functional Screening
Single Leg Squat
Functional Screening
Bilateral Leg Squat
Functional Screening
FHB Isolation
Functional Screening
Step-Down Test
Functional Screening
STAR Excursion Test
Functional Screening
Swing Test
Heel Pain in Runners
Plantar Fasciitis• 10% U.S. Population• 600,000 outpatient visits annually• 7-9% all running injuries
Plantar Fascia• Thick aponeurosis• Arises from medial
calcaneal tuberosity• Spans arch• Bands circle flexor
tendons• Insert proximal
phalanx
Functions During Gait Cycle• Heel strike: Allows midfoot to become flexible,
absorb shock, conform to uneven surface• Toe off: Windlass Mechanism: Shortening
increases arch, locks midtarsal, stabilizes toe off
Pathophysiology
• Overuse• Inflammation• Chronic changes (collagen necrosis,
angiofibroplastic hyperplasia, chondroid metaplasia, matrix calcification)
• Tearing• Medial vulnerable (thin, limited vascular
supply, limited ability to stretch
Risk Factors• Obesity• Excessive time on feet• Limited ankle motion (tibiotalar)• Limited great toe mobility (extension)• Inflexibility (HS and achilles)• Pes cavus• Pes planus• Leg length inequality (short leg)
Presentation• Plantar heel pain• A.M. pain• Mid arch (sprinters)• Increased pain with
running• Imaging primarily to rule
out other causes
Treatment
• Relative Activity Modification• Anti-inflammatories• Flexibility (HS, gastroc-soleus, plantar fascia)• Manual therapy (ankle and great toe mobility:
tibiotalar subtalar, great toe)• Strength (Foot intrinsics, ankle stability, lower
quarter stability)
Treatment (cont)
• Devices – CTF brace, heel cushions• Low dye taping• Night splints and socks• Inserts• Steroid injections
Treatment (cont)
• ESWT (> 12 mos)• Botulinum A• Autologous blood• PRP• Prolotherapy
Recalcitrant Cases
• Confirm diagnosis• Surgical release– 75-95% “some improvement”– 27% significant pain– 20% activity restriction
• Fasciectomy + neurolysis of nerve to ADM• Percutaneous plantar fasciotomy• Flouroscopically-assisted fasciotomy• US guided fasciotomy
Heel Pain Differential
• Fat Pad Insufficiency• Calcaneal Stress Fracture
Heel Pain Differential (cont)
• Neuropathies– Tarsal Tunnel Syndrome– Medial plantar nerve
(“Joggers Foot”)– First Branch, Lateral
Plantar nerve (“Baxter’s Neuropathy”)
– Radiculopathy
Heel Pain Differential (cont)
• Tendonopathies– PTTD (posterior tibial)– Flexor– Peroneal– Achilles
Heel Pain Differential (cont)
• Spring Ligament injury
Heel Pain Differential (cont)
• Bursitis– Pre-achilles– Retrocalcaneal
Heel Pain Differential (cont)
• OS Trigonum Syndrome (differentiate from posterior talus fracture)
Heel Pain Differential (cont)
• Haglund’s
Heel Pain Differential (cont)
• Sever’s Syndrome (kids)
Heel Pain Differential (cont)
• Achilles enthesopathy (consider inflammatory)
Heel Pain Differential (cont)
• Tarsal coalition
Heel Pain Considerations
• Ankle mobility (tibiotalar, subtalar great toe)• Flexibility (HS, GS, PF)• Ankle stability• Lower quarter stability
Stress FracturesFailure of bone to adapt adequately to mechanical loads (ground reaction forces and muscle contraction) experienced during physical activity
1. Tibia2. Metatarsals3. Fibula4. Navicular
Stress Fractures - Pathophysiology
Stress Fractures (cont)
• Non-critical (relative rest 6-8 wks)• Medial tibia• Metatarsals 2,3,4
Stress Fractures (cont)
At risk fractures:– Femoral neck– Anterior tibia– Medial malleolus– Navicular– Base 5th metatarsal
Femoral Neck
Superior (distraction) – higher incidence worsening/ non union
Inferior – (compression)
Anterior Tibia
Casting vs relative rest up to 6-8 months
If no healing – ortho (transverse drilling, grafting, medullary fixation)
Navicular• Tender N-spot• Critical zone middle 1/3• Non-weight bearing 6-8
weeks• Progressive activity
over 6 more weeks
Proximal 5th Metatarsal
• Jones fx of proximal diaphysis• Cast 6-10 weeks• Non-union: ortho• Consider ortho early in
competitive• Contrast with avulsion:
symptomatic RX
Patellofemoral Syndrome• Pain associated with the
articular surface of the patella and femoral condyles, its alignment and motion
• “Runners Knee” #1 presenting complaint to Runner’s Clinics
• #1 cause lost time in basic training military recruits
PFS - Classification
• Patellofemoral instability• PFS with malalignment• PFS without malalignment
PFS – Contributing Factors
• Bony abnormalities• Malalignment • Soft tissue abnormalities
PFS – Bony Abnormalities
• Dysplasia of femur
• Asymetry of patellar facets
PFS – Lower Extremity Malalignment
• Femoral anteversion• Increased Q angle• Knee valgus (knock kneed)• Lateral patellar tilt• Lateral tibial tuberosity• Abnormal tibial torsion• Hyperpronation• Restricted dorsiflexion
PFS – Muscle/Soft Tissue Imbalances
• Weak, delayed activation VMO• Weak quads• Tightness Quads, ITB, hamstring, gastroc• Weak hip muscles , abductors, gluts
Patellofemoral Syndrome - Diagnosis
• Anterior, peripatellar, subpatellar pain• Downhill and downstairs• Theater sign• Contributing factors• Apprehension (shrug) sign• X-ray
Patellofemoral Syndrome - Treatment
• Correct the functional deficits!• Bracing, taping• Foam roller• Correct pronation (if excessive)• Adjust training – avoid hills, bike mod• Correct the functional deficits!
Shoes
• Lots of options (a good thing)• Can affect impact forces, loading rates, torque forces• ? Relation to shoes, form or both• Rarely does “one size fit all”• If it ain’t broke, don’t fix it?• All transitions gradual• With barefoot, minimalist ensure stability and form
cues
• Cross train (aqua run, eliptical bike)• Walk, then walk – jog, then run• 10% per week rule• Long run increases no more than 2 miles
Relative Activity Modification Guidelines
Rule #1
• If you feel mild pain (0-3/10): it is OK to run• If you feel moderate pain (4-6/10): reduce activity
until pain level is mild.• Severe pain (> 7/10): no running
Relative Activity Modification Guidelines
Rule #2
• Pain that decreases with activity is OK.• Pain that gets worse with activity is bad; time
to reduce or stop activity.
Relative Activity Modification Guidelines
Rule #3
• No limping allowed.• If the pain alters your gait pattern, it is time to
reduce or stop the activity until you have normal biomechanics.
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