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5.15.08 Justin A. Glass, MD Emory Family Medicine.

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Presentation on theme: "5.15.08 Justin A. Glass, MD Emory Family Medicine."— Presentation transcript:

1 5.15.08 Justin A. Glass, MD Emory Family Medicine

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3 Stephen J. Carrera/European Pressphoto Agency

4  Objectives:  You will be able to give general advise regarding preventive care of runners  You will understand how to evaluate and treat common running injuries  You will be inspired to exercise for your personal health and as a role model for your patients

5  15.1 million regular runners (>100 day/yr)  3.65 billion runs (2006)  8.5 million race finishers (2006)  Sex: M 53% / F 47%  Average age: 44  College graduate: 74% http://www.runningusa.org/cgi/index_largest_races.pl

6  To prevent arthritis, you should run. True / False

7  No link between running and arthritis in anatomically normal joints  Modifiable risk factors for osteoarthritis  Weight  Certain sports / Occupations J Rheumatol 1993 Mar;20(3):461-8 JAMA 1986 Mar 7;255(9):1152-4 Menopause 2007 Sept-Oct; 14(5): 830-4

8  Mechanism of injury Stress = Load x Intensity Load = Distance Intensity = Speed

9  Prevention  Surface  Shoes  Frequency  Mileage  Speedwork  Clothing

10  Wear patterns

11  Limit mileage increase to 10% / week  Hold steady every third week  Frequency needs individual tailoring

12  Speedwork  Most running at easy pace (65-80% HR max)  Minority of time spent running at “quality level” ▪ Marathon pace training: 80-85% HR max ▪ Occas component of marathon program ▪ Tempo training: 85-92% HR max ▪ Use: limit to 10% of total weekly mileage ▪ Interval training: 98-100% HR max ▪ Use: limit to 8% of total weekly mileage

13  Weather appropriate  Reflective  Road safety awareness

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15  Case #1: 24 yr old female recreational runner develops bilat knee pain while running. Worsening over past 2 months. Running 3-4 days week. Pain also now while using stairs.

16  Case #1 - Exam  Gait normal  Knee ROM normal  No knee effusion  No joint line pain.  Mild pain with patellar manipulation  Ligaments / meniscal testing normal

17  Females > Males  Maltracking of patella www.afp.org

18  Treatment  Rest / Reduce mileage  Pharmacologic ▪ Naprosyn short term help (B Recommendation)  PT ▪ VMO strengthening (B Recommendation) ▪ Ultrasound ▪ Stretching (B Recommendation) ▪ Orthosis (B Recommendation)

19 www.aafp.org/afp/20070201/342-f2.jpg Patellar Brace

20 McConnell Taping

21  Case #2: 31 yr old male presents with a two week history of lateral knee pain. Pain occurs with running. He is planning to run a marathon in six weeks.

22  Case #2 - Exam:  Gait normal  No knee effusion noted  No pain w/ patellar manipulation  No joint line pain

23  Ober’s Test www.aafp.org/afp/20050415/1545_f2.jpg

24 www.aafp.org/afp/20050415/1545_f1.jpg

25  IT Band Syndrome Treatment  Reduction in mileage  Icing  Stretching (B recommendation)  Hip abductor strengthening (B recommendation)

26  Best Stretch www.aafp.org/afp/20050415/1545_f4.jpg

27 Another Stretch:  Iliotibial band and buttock stretch (right side shown). Position yourself as shown above. Twist your trunk to the right and use your left arm to "push" your right leg. You should feel the stretch in your right buttock and the outer part of your right thigh. Hold the stretch for 10 to 20 seconds. Do the exercise 5 to 10 times.

28 Gluteus Medius Strengthening www.aafp.org/afp/20050415/1545_f4.jpg

29  IT Band Syndrome Treatment  Reduction in mileage  Icing  Stretching (B recommendation)  Hip abductor strengthening (B recommendation)  Immobilization x short duration  Injection  Surgery

30 www.aafp.org/afp/20050415/1545_f4.jpg

31  Case #3: 37 yr old male runner presents with heel pain progressively worse over past month. No clear trigger. Worse in the morning.

32  Exam: Achilles tendon wnl. Ankle joint wnl. Medial heel tenderness on palpation

33  Plantar Fasciitis – Treatment  Stretching (B recommendation)  Ice massage  Shoe change ▪ Motion control shoe ▪ Inserts  Night splints (B recommendation)  Injection

34  Treatment  Stretching

35  Night Splints www.treatplantarfasciitis.com/plantar-fasciit - Need to use consistently - Does not replace daytime stretching -Tolerance varies among patients

36  Case #4: 42 yr old male presents with medial R knee pain. Planning to run half marathon in 2 weeks. Tripped and fell one week before pain onset on training run.

37  Case #4: Exam  R knee: No effusion No joint line pain Tenderness to palpation 4 cm below joint line medially.

38  Case #4: Pes Anserine Bursitis  What in the world is the pes anserine bursa?

39  Treatment  Ice  Rest / Reduction in mileage  Stretching  Corticosteroid Injection (consider as early intervention)

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41  Case #5: 16 yr old female on h.s. x-country team. Develops pain in R mid-foot with running in mid-season. Able to race. Comes to see you the week before district meet due to increased pain.

42  Case #5: Exam  R foot without edema  Tenderness over mid-metatarsal area.  Ankle join wnl

43  Case #5 Foot xray www.rad.msu.edu

44  Distribution  Tibia 50%  Metatarsal 25%  Fibula 10%  Femoral neck 4%  Femoral shaft 2%  Navicular <2%  Calcaneal <2%

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46  Treatment  Activity modification  Plus consideration of: ▪ Short course non-weight bearing ▪ Pneumatic splint (tibia)  Surgery ▪ Non-union www.anklebrace.info/aircast/leg-brace-big.jpg

47  Case #6: 36 yr old male training for first half marathon. Avid hiker. Began running eight weeks prior to race. Developed upper L thigh pain with running two weeks prior to race. At mile six of race had increased pain, but kept running. At mile 13 had excruciating pain in L thigh and could not run further. Needed help to walk to finish line.

48  Femoral Neck Fracture

49 http://www.emedicine.com/sports/topic37.htm

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51 http://www.aafp.org/afp/991015ap/1687.html

52  General risk factors  Shoes / Frequency / Distance / Speed  Females at high risk  Female Athlete Triad

53  Case #7: 46 yr old female:  Ran initial ING Atlanta Marathon 3/25/07  Warm day (T 56-72 over course of race)  Slow runner (5:41 marathon)  Aid stations ran out of Gatorade  Drank water throughout race

54  At finish, felt lightheaded.  Drank Gatorade  Continued to feel lightheaded with movement  To ER

55  T 99 BP 110/62 P 88 R 18  Exam unremarkable  Orthostatics negative

56  Na 122 K 3.7 Cr 0.7 Gluc 93  CPK 670  Urine osm 58 Urine Na 9

57  Prevention  Do not force fluids.  Drink fluids with glucose & electrolyte replacement

58 www.nytimes.com

59  Sudden Death while running  0.8 – 1.2 / 100,000 marathon runners  403,000 marathon finishes in 2007 BMJ 2007;3 35:1275-1277 (22 December) Sports Med 2007 2;37(4-5):448-50. www.marathonguide.com/features/Articles/2007RecapOverview.cfm#TotalFinishers

60  Average age: 41  Sex: 81% male  21/24 with coronary atherosclerosis  Contributing causes:  Electrolyte abnormalities (4)  Coronary anomalies (2)  Heat stroke (1) Competing Risks of Mortality with Marathons: Retrospective Analysis: BMJ 2007;3 35:1275-1277 (22 December)

61  Prevention is important in keeping runners running  Corollary: A runner who isn’t running is likely to be an extremely unpleasant person  Consider PFPS and ITBS in running assoc knee pain  Plantar fasciitis is the most common etiology of heel pain  Consider a stress fracture in a runner presenting with focal pain in the mid-foot / shin / hip  Dilutional hyponatremia can be prevented with proper fluid intake  Sudden cardiac death while running is rare

62  Common Problems in Endurance Athletes, Cosca et al, Am Fam Physician 2007; 76: 237-44.  Management of Patellofemoral Pain Syndrome, Dixit et al, Am Fam Physician 2007; 75: 194-202.  Treatment of Plantar Fasciitis, Young et al, Am Fam Physician 2001; 63:467-74.  Common Stress Fractures, Sanderlin et al, Am Fam Physician 2003; 68: 1527-32.  Diagnostic & Therapeutic Injection of the Hip & Knee, Cardone, DA, Am Fam Physician 2003;67:2147-52.  Running Injuries, Noakes & Granger, Oxford Press, 1996.  Daniels’ Running Formula, Human Kinetics, 2005

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