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Slide 1-

Running Injuries: Evaluation, Treatment, Prevention Rebecca M. Northway, MD Internal Medicine-Pediatrics Primary Care Sports Medicine USA Hockey NTDP Team Physician
Slide 2-

Disclosures I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider(s) of commercial services discussed in this CME activity
Slide 3-

Objectives Discuss Common Running Injuries Identify Possible Risk Factors for Running Injuries Briefly Discuss Evaluation of Various Running Injuries Discuss Treatment of Common Running Injuries Review Possible Preventive Strategies
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Why Run? Increase focus on healthy lifestyle Convenient Flexible Affordable Minimal Equipment Individual or Group Participation Health Benefits Mental Health
Slide 5-

Running Injury Incidence Annual rates of running injuries 19.4%-79.3% Incidence in those training for a marathon is as high as 90% Experienced runners are less frequently injured Most injuries are overuse
Slide 6-

Running- The Basics Gait Cycle Begins with heel strike of one foot and ends with heel strike of the same foot Has 2 basic periods, stance 60% and swing 40% Stance can be broken into 3 (or 4) phases Initial contact, (flat foot), Mid stance, Push/Toe Off Swing begins once the foot is no longer in contact with the ground and has 3 phases Acceleration, Mid Swing, Deceleration
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Running- The Stance Period Initial Contact Mid Stance Toe- Off Foot strike or impact Actively decelerates the forward- swinging leg Passively absorbs the shock of the ground reaction Foot makes full contact Body weight shifts from rear to forefoot Lengthening LE with concentric contraction of hip and knee extensors Push off to propel runner forward
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Running- The Swing Phase Initial Swing Mid Swing Terminal Swing Foot advances forward through the air Foot positions itself for weight acceptance 3 Foot Strikes: Rear, Mid, Fore Foot Most injurious the moment is when the foot collides with the ground
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Terminology GRF at initial contact Ground Reaction Force: forces exerted by the ground on the foot Impact forces: when foot comes to sudden stop upon impacting ground Concern has been with various foot strike patterns creating higher collision forces
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Established Risk Factors Extrinsic Training program/errors Shoes Running surface Mileage Intrinsic Poor flexibility Malalignment Muscle imbalance Previous injury Running experience Competitive nature Age/Sex 3 most common independent risk factors: Increase in mileage too quickly Previous injury Competitive training motive
Slide 11-

Extrinsic Risk Factors-Training Program Ask about training program Specific program, cross training, etc Running without a break from training Training for more than 1 year Less is more? Running 1-3 days/week less likely to be injured Change in training technique 1/3 of those injured had changed training technique or shoes
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Extrinsic Risk Factors- Mileage Ask about Mileage Longest run, total distance, recent change Running distance is considered to be one of strongest contributors to injury Increase in training distance Injury rate increases with >20m/wk Increase injuries in marathoners Longer races associated with LE injuries
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Extrinsic Risk Factors- Shoes Ask about and evaluate shoes Type, how long worn, recent change No studies with sufficient quality of evidence for “shoe prescription” Many shoes have medial posts or varus wedges Increase supination Shoes should be replaced every 300-500 miles
Slide 14-

Extrinsic Risk Factors- Surface Type No statistical evidence to link surface type to injury rates Some surfaces have been linked to certain injuries: Harder- PFPS and tibial stress Loose surface- meniscal Up/down hill- ITB and patellar tendinopathy
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Intrinsic Risk Factors- Previous Injury Ask about previous injury Where, when, evaluation and rehab Previous injury is a significant predictor of re-injury “The timing of recovery is just as important as the loading of exercise” Incomplete healing, uncorrected biomechanical abnormality, abnormal functioning of repaired tissue contributes to re-injury Studies have shown the injured runners have an almost 75% increased risk of sustaining another injury
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Intrinsic Risk Factors- Age and Sex and Experience Incidence of injury decreased with age and increases with less experience BUT duration of symptoms of injury increased in older injured runners Mean age of 30-40’s for injuries Is there selection bias as only injury free persons continue to run?
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Intrinsic Risk Factors- Malalignment Pes Cavus- more rigid foot Recurrent stress fractures, PFPS Overpronation Leg Length Discrepancy Anatomical Biomechanical Muscle flexibility Knee alignnment Genu Varus: PFPS, ITBFS, Tibial stress fx Genu Valgus: PFPS, patellar tendinopathy
Slide 18-

Intrinsic Risk Factors- Muscle Imbalance Closed kinetic chain theory If one joint of lower extremity is not functioning properly, injuries manifest in other joints Proximal core hip strength needed to control distal segments At foot strike the trunk laterally flexes towards same side Stabilized by balancing contraction of hip abductors
Slide 19-

Intrinsic Risk Factors- Muscle Imbalance Hip muscle weakness and overuse injuries Injured side Weak hip abduction and external rotation Hip flexors weaker, hip adductors stronger Trend towards hip extensor weakness Abdominal muscles control stability of pelvis Athletes with injury Less core stability Lower abdominal performance
Slide 20-

Location of Injury 5 most common injuries: PFPS ITBF syndrome Plantar fasciitis Medial tibial stress syndrome Knee meniscal injuries Most injuries are overuse rather than acute
Slide 21-

Case 1 25 year old runner Anterior knee pain, difficult to pinpoint Described as achy Present with prolonged sitting Can still run but worse on hills
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Patellofemoral Pain Syndrome Anterior knee pain in/around patella PFJ load 5-7x body weight with flexion Pathologic origin is not clearly understood and is not the same for all patients Abnormal tracking of patella Excessive Q angle Deficient vastus medialis obliqus Tight vastus lateralis and lateral structures Genu Valgum/recurvatum Over-Pronation, innominate pelvis, leg length discrepancy Irritation of surrounding structures
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Patellofemoral Pain Syndrome Exam +/- crepitus TTP of medial and lateral patella facets Poor Vastus Medialis Obliques (VMO) Inflexibility of lateral structures + load and grind and inhibition test Functional testing Poor core, glut, hip strength Imaging Xray- consider sunrise/merchant view MRI- not usually indicated
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Treatment: Rationale for PT is alleviation of pain by restoration of patellar alignment Reduction of pain/inflammation NSAIDs, ice, rest, US Improving flexibility of lateral structures VMO retraining and strengthening Hip, core, glut muscle strengthening Patella taping Orthotics Non op is the mainstay One rehab protocol for al PFPS patients does not exist Patellofemoral Pain Syndrome
Slide 25-

Patellofemoral Pain Syndrome Gait analysis Important in any runner with injury Look at stride, landing, entire leg Needs to be done by a trained individual
Slide 26-

Patellar Tendionpathy “Jumper’s knee” Degenerative tendinosis TTP on exam and also with functional testing Inferior pole of patella or tendon Check for PFPS, abnormal PFJ biomechanics Imaging None needed
Slide 27-

Patellar Tendinopathy Treatment: Patience! First time- 3-6 months to recover Long standing - may be 6-12 months Eccentric strengthening 25 incline board US, massage, friction therapy Hip, core, glut muscle strengthening Chopat strap Referral Sports Medicine if recalcitrant
Slide 28-

Case 2 55 year old runner Lateral knee pain Some swelling after running Noticed after doing a trail ½ marathon Feels a clicking at times Has had to decrease running
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Meniscal Injuries Shear stress with knee flexion and compression and femoral rotation Twisting mechanism, degenerative May not have immediate symptoms Exam: Joint line TTP (knee flexed 45-90°) +/- Effusion Decreased ROM McMurray’s test Apply Grind test Thessaly test
Slide 30-

Meniscal Injuries Imaging: Xray: Can show OA MRI: best imaging tool to diagnose Consider if changes treatment plan or question on clinical exam Treatment: Conservative initially RICE, PT, CS injections, braces (hinged or unloader), modify activity Surgery if large or unresponsive to conservative treatment, or young age
Slide 31-

ITB Friction Syndrome Friction between ITB and lateral femoral epicondyle During foot strike Aggravated by downhill running or uneven surface Exam: + Ober’s & Noble Tight TFL and gluteal muscles but weak strength
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ITB Friction Syndrome Treatment: Symptomatic treatment Ice, NSAIDs Stretching Soft tissue friction massage Foam roller, trigger point Strengthening hip and glut muscles Gait Analysis CS injection
Slide 33-

Case 3 45 year old overweight female Started a running program to loose weight Having pain in her heel Worse first thing in the morning Told she has a heel spur in the past
Slide 34-

Plantar Fasciitis Heel or arch pain, often with first steps Pain at insertion of the medial calcaneal tuberosity Heel spur is incidental finding on Xray
Slide 35-

Plantar Fasciitis Treatment: Rest, NSAIDs Stretching plantar fascia, gastroc and soleus Straussburg sock Massage with frozen water bottle Supportive shoes with arch at all times Silicone heel pad or orthotics PT Soft tissue therapy, US, strengthening Recalcitrant cases: CS inj, ECSWT, Tenex
Slide 36-

Achilles Tendinopathy Pain in either midportion or insertion TTP, thickening, crepitus Unilateral calf tightness Functional testing Heel raises, hop Imaging Xray- may show calcification or enthesophytes US can show chronic inflammatory changse Musculo-tendinous jxn Classic Midportion Insertion
Slide 37-

Achilles Tendinopathy Treatment: Rest Orthotics Stretching Eccentric strengthening Nitric Oxide donor therapy Soft tissue therapy on calf and also tendon Alfredson’s Eccentric painful heel drop protocol Gastro- knee fully extended Soleus- knee flexed to 45 Both start in demipointe with heel raised and lower until foot parallel with ground Once no longer pain, increase intensity
Slide 38-

Case 4 35 year old male Has been doing a lot of 5k races Started getting posterior buttock and leg pain Worse on end of race with stride lengthening
Slide 39-

Hamstring Strain More related to explosive ballistic activity Very high recurrence rate- 30% + Most at the muscle-tendon junction of the biceps femoris Exam TTP (check ischial tuberosity), deformity, flexibility, strength Graded based on pain and strength 1- pain but strong 2- painful and weak 3- extremely weak but painless
Slide 40-

Hamstring Strain Imaging: Pelvic X-ray Treatment: Relative to the grade RICE NSAIDs may blunt normal healing Crutches if limp or avulsion Referral Sports Medicine PT Soft tissue and manual therapy, modalities Stretching, eccentric strengthening, progression to activities
Slide 41-

Case 5 18 year old runner Training for college cross country team Anterior shin pain on beginning of run that dissipates later No pain at rest
Slide 42-

Medial Tibial Stress Syndrome Continuum of “shin splints” or traction periostitis, stress fracture, frank fracture Progression of pain 90% involve the posteromedial aspect of tibia Mid to distal 1/3 High risk is anterior or proximal Exam TTP, callus formation Positive hop test, vibration/tuning fork
Slide 43-

Medial Tibial Stress Syndrome Evaluation/Treatment: Tib/Fib Xray is usually negative MRI preferred over Bone Scan Referral to Sports Medicine Rest and activity restriction Crutches if pain with walking/ADLs, limp Ice PT Once pain free when walking and no TTP, can gradually progress, starting with cross training Usually takes 2-3 months until full RTP
Slide 44-

Hip and Pelvis Overuse Injuries Gluteal tendinosis Pain at the insertion or musculo-tendon junction and bursa Pain with resisted strength testing Clam, side lying st leg extension PT: eccentric exercises, core strength US guided CS inj Greater trochanteric bursitis TTP of the bursa lateral to the greater trochanter Rest, PT with stretching/strengthening, CS injection Gluteus medius bursa Trochanteric bursa
Slide 45-

Hip and Pelvis Overuse Injuries Piriformis syndrome TTP, piriformis stretch, pain with resisted external rotation sciatic nerve passes through in 10% PT: stretching external rotators, core strength, massage SI joint dysfunction TTP over SI joint, leg length discrepancy, trendelenburg gait, FABER test PT with core stability and focus on abdomino-lumbo-sacro-pelvis-hip complex
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Prevention Shoes/orthotics/insoles No significant reduction in injuries Assess need/response with gait analysis Stretching Insufficient evidence in reduction of injuries Graded program To minimize risk of injury most recommend not increasing training by more than 10% per week Cross training and strength training Barefoot/chi
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Conclusion Running is a very popular economical sport Multifactorial etiology of running related injuries The history is extremely important in diagnosis Difficult for runners of all levels to follow the advice to “stop running”
Slide 48-

Thank You
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References van Gent RN, Siam D, van Middelkoop M, et al. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sports Med 2007;41:469-480. Yeung EW, Yeung SS. A systematic review of interventions to prevent lower limb soft tissue running injuries. Br J Sports Med 2001;35:383-389. Johnston CAM, Taunton JE, Lloyd-Smith DR, McKenzie DC. Preventing running injuries: practical approach for family doctors. Can Fam Physician 2003;49:1101-1109. Taunton JE, Ryan MB, Clement DB, et al. A prospective study of running injuries: the Vancouver Run “In Training” clinics. Br J Sports Med 2003;37239-244. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36:95-101. Jacobs S, Berson B. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med 1986;14;151-155. Buist I, Bredewg W, Lemmink K, et al. Predictors of running-related injuries in novice runners enrolled in a systematic training program. Am J Sports Med 2010;38: 273-280
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References Marti B, Vader JP, Minder C, Abelin T. On the epidemiology of running injuries: the 1984 Bern Grand-Prix study. Am J Sports Med 1988;16:285-294. Niemuth P, Johnson R, Myers M, Thieman T. Hip muscle weakness and overuse injuries in recreational runners. Clin J Sport Med 2005;15:14-21. Leetun D, Ireland M, Willson J, et al. Core stability measures as risk factors for lower extremity injury in athletes. Med Sci Sports Exerc 2004;36:926-934. Rolf C. Overuse injuries of the lower extremity in runners. Scan J Med Sci Sports 1995;5:181-190. Fields K, Sykes J, Walker K, Jackson J. Prevention of running injuries. Curr Sports Med 2010;9:176-182. Hreljac A. Impact and overuse injuries in runners. Med Sci Sports Exerc 2004;36:845-849. Ferber R, Hreljac A, Kendall K. Suspected mechanisms in the cause of overuse running injuries: a clinical review. Sports Health 2009;1: 242-246. Fredericson M, Misra A. Epidemiology and aetiology of marathon running injuries. Sports Med 2007;37:437-439
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References Robbins S, Hanna A. Running-related injury prevention through barefoot adaptations. Med Sci Sports Exerc 1987;19:148-156. Hoeberigs J. Factors related to the incidence of running injuries. Sports Med 1992;13:408-422. Hreljac A, Marshall R, Hume P. Evaluation of lower extermity overuse injury potential in runners. Med Sci Sports Exerc 2000;32:1635-1641. Sato K, Mokha M. Does core strength training influence running kinetics, lower extremity stability, and 5000-m performance in runners? J Strength Cond Research 2009;23;133-140. Brill P, Macera C. The influence of running patterns on running injuries. Sports Med 1995;20:365-368. http://barefootrunning.fas.harvard.edu/index.html Lieberman DE, Venkadesan M, Werberl WA et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature 2010;463:531-535. Brukner Peter and Karim Khan. Clinical Sports Medicine (3rd). Australia: McGraw-Hill Australia, 2009.