Dr Robert Wilder 2114 - Richmond Endurance Athlete Symposium

Report
Common Running Injuries
Robert P. Wilder, MD, FACSM
Chair, Physical Medicine & Rehabilitation
The University of Virginia
Medical Director, The Runner’s Clinic at UVA
Team Physician, Ragged Mountain Racing
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 runners
70% all runners sustain significant injury
40% knee
15% each: shin, achilles, hip/groin
10% foot and ankle
5% spine
25% recreational
5% elite
Epidemiology of Running Injuries
4% bit by dogs
0.3% hit by bicycles
0.6% hit by cars
7% hit by thrown objects
Principle of Transition
“Culprits & Victims”
Intrinsic Abnormalities
Malalignment
Muscle imbalance
Inflexibility
Muscle weakness
Instability
Extrinsic Abnormalities
Training errors
Equipment
Environment
Technique
Sport-imposed deficiencies
Examination of the Injured Runner
History
Biomechanical assessment
Site-specific exam
Dynamic exam
Shoe exam
Ancillary testing
radiologic
electrodiagnostic
compartment testing
History
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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
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Biomechanical assessment
Site specific examination
Dynamic examination
Ancillary testing
Shoe examination
Functional Screening
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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
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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
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Plantar heel pain
A.M. pain
Mid arch (sprinters)
Increased pain with
running
• Imaging primarily to rule
out other causes
Treatment
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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)
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Devices – CTF brace, heel cushions
Low dye taping
Night splints and socks
Inserts
Steroid injections
Treatment (cont)
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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
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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
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Ankle mobility (tibiotalar, subtalar great toe)
Flexibility (HS, GS, PF)
Ankle stability
Lower quarter stability
Stress Fractures
Failure of bone to adapt
adequately to mechanical
loads (ground reaction
forces and muscle
contraction) experienced
during physical activity
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Tibia
Metatarsals
Fibula
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
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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
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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
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Weak, delayed activation VMO
Weak quads
Tightness Quads, ITB, hamstring, gastroc
Weak hip muscles , abductors, gluts
Patellofemoral Syndrome - Diagnosis
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Anterior, peripatellar, subpatellar pain
Downhill and downstairs
Theater sign
Contributing factors
Apprehension (shrug) sign
X-ray
Patellofemoral Syndrome - Treatment
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Correct the functional deficits!
Bracing, taping
Foam roller
Correct pronation (if excessive)
Adjust training – avoid hills, bike mod
Correct the functional deficits!
Shoes
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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
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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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