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Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

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Presentation on theme: "Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,"— Presentation transcript:

1 Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician, Ragged Mountain Racing Common Running Injuries

2 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

3 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

4 Epidemiology of Running Injuries 4% bit by dogs 0.3% hit by bicycles 0.6% hit by cars 7% hit by thrown objects

5 Principle of Transition Culprits & Victims

6 Intrinsic Abnormalities Malalignment Muscle imbalance Inflexibility Muscle weakness Instability

7 Extrinsic Abnormalities Training errors Equipment Environment Technique Sport-imposed deficiencies

8 Examination of the Injured Runner History Biomechanical assessment Site-specific exam Dynamic exam Shoe exam Ancillary testing radiologic electrodiagnostic compartment testing

9 History Prior injury history Team/Club Identify transitions MPW (20, 40) Long run (< 1/3 weekly total) Intensity Surface (? Muscle tuning) Shoes/orthotics ( miles) Cross Training Goals Life Stressors/fatigue Females: eat d/o, menstrual irreg, osteopenia

10 Physical Examination Biomechanical assessment Site specific examination Dynamic examination Ancillary testing Shoe examination

11 Functional Screening Single Leg Stance Single Leg Squat Bilateral Squat FHB isolation Step-down Test STAR Excursion Test Swing Test

12 Functional Screening Single Leg Stance

13 Functional Screening Single Leg Squat

14 Functional Screening Bilateral Leg Squat

15 Functional Screening FHB Isolation

16 Functional Screening Step-Down Test

17 Functional Screening STAR Excursion Test

18 Functional Screening Swing Test

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20 Heel Pain in Runners

21 Plantar Fasciitis 10% U.S. Population 600,000 outpatient visits annually 7-9% all running injuries

22 Plantar Fascia Thick aponeurosis Arises from medial calcaneal tuberosity Spans arch Bands circle flexor tendons Insert proximal phalanx

23 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

24 Pathophysiology Overuse Inflammation Chronic changes (collagen necrosis, angiofibroplastic hyperplasia, chondroid metaplasia, matrix calcification) Tearing Medial vulnerable (thin, limited vascular supply, limited ability to stretch

25 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)

26 Presentation Plantar heel pain A.M. pain Mid arch (sprinters) Increased pain with running Imaging primarily to rule out other causes

27 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)

28 Treatment (cont) Devices – CTF brace, heel cushions Low dye taping Night splints and socks Inserts Steroid injections

29 Treatment (cont) ESWT (> 12 mos) Botulinum A Autologous blood PRP Prolotherapy

30 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

31 Heel Pain Differential Fat Pad Insufficiency Calcaneal Stress Fracture

32 Heel Pain Differential (cont) Neuropathies – Tarsal Tunnel Syndrome – Medial plantar nerve (Joggers Foot) – First Branch, Lateral Plantar nerve (Baxters Neuropathy) – Radiculopathy

33 Heel Pain Differential (cont) Tendonopathies – PTTD (posterior tibial) – Flexor – Peroneal – Achilles

34 Heel Pain Differential (cont) Spring Ligament injury

35 Heel Pain Differential (cont) Bursitis – Pre-achilles – Retrocalcaneal

36 Heel Pain Differential (cont) OS Trigonum Syndrome (differentiate from posterior talus fracture)

37 Heel Pain Differential (cont) Haglunds

38 Heel Pain Differential (cont) Severs Syndrome (kids)

39 Heel Pain Differential (cont) Achilles enthesopathy (consider inflammatory)

40 Heel Pain Differential (cont) Tarsal coalition

41 Heel Pain Considerations Ankle mobility (tibiotalar, subtalar great toe) Flexibility (HS, GS, PF) Ankle stability Lower quarter stability

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43 Stress Fractures Failure of bone to adapt adequately to mechanical loads (ground reaction forces and muscle contraction) experienced during physical activity 1.Tibia 2.Metatarsals 3.Fibula 4.Navicular

44 Stress Fractures - Pathophysiology

45 Stress Fractures (cont) Non-critical (relative rest 6-8 wks) Medial tibia Metatarsals 2,3,4

46 Stress Fractures (cont) At risk fractures: – Femoral neck – Anterior tibia – Medial malleolus – Navicular – Base 5 th metatarsal

47 Femoral Neck Superior (distraction) – higher incidence worsening/ non union Inferior – (compression)

48 Anterior Tibia Casting vs relative rest up to 6-8 months If no healing – ortho (transverse drilling, grafting, medullary fixation)

49 Navicular Tender N-spot Critical zone middle 1/3 Non-weight bearing 6-8 weeks Progressive activity over 6 more weeks

50 Proximal 5 th Metatarsal Jones fx of proximal diaphysis Cast 6-10 weeks Non-union: ortho Consider ortho early in competitive Contrast with avulsion: symptomatic RX

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52 Patellofemoral Syndrome Pain associated with the articular surface of the patella and femoral condyles, its alignment and motion Runners Knee #1 presenting complaint to Runners Clinics #1 cause lost time in basic training military recruits

53 PFS - Classification Patellofemoral instability PFS with malalignment PFS without malalignment

54 PFS – Contributing Factors Bony abnormalities Malalignment Soft tissue abnormalities

55 PFS – Bony Abnormalities Dysplasia of femur Asymetry of patellar facets

56 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

57 PFS – Muscle/Soft Tissue Imbalances Weak, delayed activation VMO Weak quads Tightness Quads, ITB, hamstring, gastroc Weak hip muscles, abductors, gluts

58 Patellofemoral Syndrome - Diagnosis Anterior, peripatellar, subpatellar pain Downhill and downstairs Theater sign Contributing factors Apprehension (shrug) sign X-ray

59 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!

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62 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 aint broke, dont fix it? All transitions gradual With barefoot, minimalist ensure stability and form cues

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64 Cross train (aqua run, eliptical bike) Walk, then walk – jog, then run 10% per week rule Long run increases no more than 2 miles

65 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

66 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.

67 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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