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Common Running Injuries

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Presentation on theme: "Common Running Injuries"— Presentation transcript:

1 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

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


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

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 (“Baxter’s 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)

38 Heel Pain Differential (cont)
Sever’s 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


43 Stress Fractures Failure of bone to adapt adequately to mechanical loads (ground reaction forces and muscle contraction) experienced during physical activity Tibia Metatarsals Fibula 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 5th 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 5th Metatarsal
Jones fx of proximal diaphysis Cast 6-10 weeks Non-union: ortho Consider ortho early in competitive Contrast with avulsion: symptomatic RX


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 Runner’s 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



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 ain’t broke, don’t fix it? All transitions gradual With barefoot, minimalist ensure stability and form cues


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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