John Hill, DO,FACSM, FAAFP University of Colorado Director of Primary Care Sports Medicine Fellowship Saturday, May 17, 2014 Better perform a focused hip examination Recognize and manage improper running biomechanics to prevent injuries Discuss how core stability impacts many running injuries Apply these principles to return the “athlete” back to running You will understand that running is not evil Most of us were born to run! Newton Shoes: Physician Advisory Board MuscleSound: Physician advisor for software development to determine muscle glycogen content using Ultrasound. After running more than 28 hours, I am still smiling, why…. I finally learned what I am going to teach you Tarahumara runner Arnulfo Quimare and Ultra-running legend Scott Jurek It is all about Biomechanics • Flexed at the waist • Heel strike • Over striding • Low arm position • Hip drops with each step • Knee collapses in valgus • No smile on his face, this dude is suffering copes with impact and takeoff --extends from spine to foot 1.Foot strike 2.Support 3.Take-off 4.Swing swing takeoff foot strikesupport Intra-articular Chondral Labral Capsular Extra-articular Systemic Snapping hip ITB tendinitis Bursitis Flexor tendinosis SI joint pain Hamstring strain Soft tissue impingement Iliopsoas Athletic pubalgia Hernia Adductor tendinosis Developmental Dysplasia of the Hip Legg Calve Perthes Disease Slipped Capital Epiphysis Previous Trauma History: symptom response Functional Movement Screen Weight Bearing tests AROM PROM with over pressure – Flexion/Abduction Manual muscle testing Distraction/Compression with movement Ligament evaluation Marching test for sacroiliac movement FABER Active/Passive: Flexion (110-120’) Extension (10-15’) Abduction (30-50’) Adduction (30’) Internal Rotation (0-50’) sup/prone External Rotation (30-90’) sup/prone Flexion: Psoas, Iliacus, rectus femoris, sartorius, pectineus, adductor long/brev, gracilis Extension: Biceps femoris, semimembranosus, semitendinosus, glut max, glut med (posterior part), adductor magnus (ischiocondylar part) Adduction: Adductor longus, adductor brevis, adductor magnus, gracilis, pectineus Abduction: Tensor fascia latae, glut minimus, glut medius, glut maximus, sartorius Internal Rotation: Adductor long/brev/magnus, Glut med (anterior part), glut minimus (anterior part), tensor fascia latae, pectineus, gracilis. External Rotation Glut max, obturator int/ext, quadratus femoris, piriformis, gemellus sup/inf, sartorius, glut med (posterior part) Flexion / Adduction / IR Flexion / Abduction / ER Gluteus Medius Strength Test Gluteus Maximus Strength Test Adductor Testing Piriformis Test + if pain with stretching piriformis muscle Fulcrum Test + if pain is elicited Site of pain is usually near site of stress fracture First recognized importance in late 1980s and early 1990s General population: multiple exercise programs and equipment focused on core stability and benefits of improving stability First recognized importance in late 1980s and early 1990s General population: multiple exercise programs and equipment focused on core stability and benefits of improving stability Does this apply to runners? No universally accepted definition of core stability Kibler: “The ability to control the position and motion of the trunk over the pelvis to allow optimum production, transfer, and control of force and motion to the terminal segment in integrated kinetic chain activities” Includes the spine, hips, pelvis, proximal lower limbs, and abdominal region Diaphragm Paraspinals and Gluteals Abdominals Pelvic Floor and Hip Girdle Musculature Strength of the core muscles: Allows the system to mechanically stabilize the spine then distribute and deliver compressive, translational, and shear forces to and from the rest of the body Plyometric training: Involves exercises in which the active muscles are stretched prior to shortening Usually requires explosive strength training Invokes specific neural adaptations (ie, increased activation of motor units) Less muscle hypertrophy than static strength training Running is a plyometric activity Rehab from injuries: Benefits from strength exercises Benefits from plyometric training Integration of the two improves your results Return to running after an injury: Must be able to demonstrate competence with plyometric exercise (proper running form) To perform plyometric exercises safely, must increase core stability with static load strength training Prevention of injury Treatment of injuries Effect on performance Back pain: delays in trunk motor control reflex are predisposing factor (Cholewicki, 2005) Patellofemoral pain: weakness in the gluteus medius predisposes to PFS (Willson, 2011) Hamstring injuries: early fatigue in abdominal muscles likely a contributor (Devlin, 2000) Knee Ligament injury: increased trunk displacement and decreased proprioception on testing predicted knee ligament injury for females, not males (Zazulak, 2007) Wide variety of movements associated with sports need sufficient strength in hip and trunk muscles in all three planes of motion Contribution of specific muscles depends on direction and magnitude of trunk loading (Cholewicki 2002) Athletes may have good core strength when tested by low exertion exams Need to do more functional testing Remember, this person is not just walking around the house and going to the grocery store 3 tests 1. Pelvic alignment 2. Single leg squat and hop test 3. Side plank with side leg raise Good pelvic alignment: horizontal waist Poor pelvic Alignmen t: forward pelvic tilt Pelvic tilt Forward tilt: often see weakness in quadratus lumborum, rectus abdominis, and obliques Single Leg Squat Global core stability Should see alignment maintained between hip, knee, and ankle Watch for contralateral hip dropping and knee moving into valgus If single leg squat performed competently, move on to lateral step down test Single leg squat Good limb alignment Single leg squat Valgus collapse of knee Single leg side step Good limb alignment Hop test Similar to single leg squat, more dynamic Requires neuromuscular control, core strength and stability Evaluate knee alignment, height of jump, and stable, aligned soft landing Side plank Both sides Measures lateral core strength—Quadratus lumborum Examiner notes how long patient can hold position Ideal length of holding: 45-60 seconds Side plank Side leg raise No trunk flexion Upper leg abducted completely with maximal hip external rotation (toe pointed to ceiling) Fully recruits gluteus medius Examiner resists motion and evaluates strength Side leg raise Combining exercises If proficient with both side plank and side leg raise combine these exercises Assess neuromuscular coordination, hip adductor strength, and abnormal recruitment of the iliopsoas Weak abductors recruit iliopsoas and see forward flexion at waist Goal to perform 30 on each side Combined side plank and side leg raise Clinicians should not assume athletes are more competent with dynamic core stability than the general population Dynamic testing can unmask subtle deficiencies Important to achieve adequate static core strength prior to pushing dynamic, plyometric rehab Often therapist or athlete will push dynamic plyometric rehab too soon re-injury Need at least 3 sets of 15 with combined activity to progress to plyometric rehab Important to maintain once athlete returned to sport Continue 3 sets of 30 of the combined side plank and side leg raise on each side, 3 days per week The focused hip examination often reveals where the problem is It is all about the biomechanics , recognize and manage improper running form Assess core stability and first fix the weakness in their static hip stabilizers Before returning a runner back to running (plyometrics) make sure their static hip stabilizers are strong Akuthota V, Ferreiro A, Moore T, et al. 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