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Common Running Injuries: Prevention & Rehabilitation Shana Margolis, MD Attending Physician, Rehabilitation Institute of Chicago Clinical Instructor, Northwestern.

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Presentation on theme: "Common Running Injuries: Prevention & Rehabilitation Shana Margolis, MD Attending Physician, Rehabilitation Institute of Chicago Clinical Instructor, Northwestern."— Presentation transcript:

1 Common Running Injuries: Prevention & Rehabilitation Shana Margolis, MD Attending Physician, Rehabilitation Institute of Chicago Clinical Instructor, Northwestern Feinberg School of Medicine Davalyn Partain, PT, DPT Physical Therapist, Department of Orthopaedic Surgery, Northwestern Medical Faculty Foundation, Rehabilitation Institute of Chicago June 16, 2010

2 Acknowledgements Christopher Plastaras, MD Joseph Ihm, MD Paul Lento, MD Jo Fasen, PT, MPT, OCS, CSCS, Cert. MDT

3 What is Physiatry? Also called physiatrists (fizz ee AT’ trists) Physical Medicine & Rehabilitation “Physicians of Function” 4 year residency program Evaluation and Treatment of all disabilities Musculoskeletal and Sports medicine is one aspect

4 Musculoskeletal Healthcare Providers Orthopedic Surgeons and Podiatrists –Operate on bones, tendons, ligaments Types of Physicians: Physical Medicine & Rehabilitation (Physiatrists) –Non-operative care of musculoskeletal problems Physical Therapists & Occupational Therapists –Specialize in designing exercises for muscle, bone, nerve problems Athletic Trainers, Physical Therapists Assistants & Aids –Work closely with physical therapists to instruct on proper exercise technique Running Coaches, Personal Trainers, Pilates/Yoga Instructors –Advance physical fitness in people without pathology or pain Physicians –Diagnose –Order tests –Prescribe Meds –Prescribe therapy –Prescribe interventions (injections/surgery) Chiropractors –Specialize in manual assessment and treatment of musculoskeletal problems Pedorthotist –Make & advise orthotic devices, shoes, braces

5 What is running? One leg hopping Leg absorbs force Requires flexibility Requires hip girdle strength Lengthening Contraction –Most damaging to muscle and requires great strength –Fatigue?

6 Running Injury Prevention

7 Injury Risk Factors Extrinsic factors –Training errors –Equipment Shoe type Shoe age –Environment Surface type CamberDirection Intrinsic factors –Bone alignment –Muscle imbalance –Biomechanical deficits

8 Kinetic Chain Focus Proximal segments can influence distal segment motion Distal segments can influence proximal segment motion Christopher M. Powers, PT, PhD JOSPT November 2003 Vol. 33 No. 11 The Influence of Altered Lower-Extremity Kinematics on Patellofemoral Joint Dysfunction: A Theoretical Perspective

9 Causes of Injury Trauma (less common) Overuse –“Too Much Too Soon Too Fast” –Asymmetries Previous injury Inflexibility/strength differences Terrain (cambered/hills) Terrain (cambered/hills)

10 Training Errors too much, too soon, too fast Increased injury rate beyond 20 miles/week Inadequate warm-up Inadequate flexibility and strength Inadequate rest between runs Too many miles, too soon Too much interval/speed training

11 Running Injuries Proper diagnosis of injury Understand goals Treat underlying cause Treat kinetic chain Make sense, be functional

12 Injury Evaluation History of problem Biomechanical evaluation Site-specific evaluation Running assessment Shoe assessment

13 Common Injuries/Problems Hips/Knees –Patellofemoral Pain –Iliotibial Band Pain –Greater Trochanteric Bursitis Feet/Ankles –Plantar Fasciitis –Achilles tendonitis “Shin Splints” Stress Reaction/Fractures Hydration

14 Hip & Knee Pathology

15 Patellofemoral Pain “Runner’s Knee” Pain located beneath and/or around knee cap Softening and compression of cartilage under the knee cap >25% incidence in athletes Females > Males

16 Patellofemoral Pain Vague, achy pain in front part of knee Worse with going downstairs Pain when knee bent for long time (like in the movie theatre) Worse with hills

17 Careful physical examination Biomechanical evaluation Running gait evaluation X-rays usually normal in mild/early cases MRI if not getting better Patellofemoral Pain Evaluation

18 Understanding Function  Abnormal knee cap tracking, abnormal alignment  Knee cap runs on femur “like train on tracks”

19 Patellofemoral Pain Causes Weak hip and core muscles cause knee cap to track improperly Tight quadriceps Overpronation of the foot Rigid foot

20 Patellofemoral Pain What do you do when you have it? Initial Treatment “PRICE” Protection Relative Rest (& Gentle Mobility) Ice Compression Elevation

21 Patellofemoral Pain What do you do when you have it? Training modification Knee bracing as prescribed Patellar mobilization, manual therapy Ice regularly

22 Patellofemoral Pain What do you do when you have it? Patellar taping: a transitional step –to encourage more force from quadriceps, help with pain Flexibility: ITB, hip flexors, hamstrings, quadriceps, calf –Quadriceps flexibility- emphasis on lower back position

23 Patellofemoral Pain Additional remedies known to work! Chopart strap Quad and ITB Massage Change shoes –get the right type for your foot OrthoticsBalance

24 Iliotibial Band Syndrome Localized tenderness on the outside of the knee Especially common when training for longer distances ~runs over 18 miles

25 Iliotibial Band Syndrome ITB passes over outside of femur bone Repetitive motion causes rubbing and inflammation –Most friction when knee is bent degrees

26 Iliotibial Band Syndrome Causes Flat feet with no motion control shoes High arches with excessive supination Due to hip girdle weakness and/or tightness Leg length difference Banked terrain, hills & stairs Increased mileage?

27 Iliotibial Band Syndrome What do you do when you have it? Initial Treatment “RICE” Relative Rest Ice Compression Elevation

28 Iliotibial Band Syndrome What do you do when you have it? Anti-inflammatories Soft tissue mobilization/massage Foam roll mobilization UltrasoundStretching Multi-planar strengthening Motion control shoes Shorten stride length

29 Trochanteric Bursitis Pain over outer hip May radiate down outside of thigh Back or deeper hip problem? Pain laying on side Increased frequency in running or contact sports Females>Males

30 Trochanteric Bursitis Causes Direct impact or fall Repetitive friction of glut med or ITB Leg length discrepancy Hip weakness Lateral hip surgery

31 Trochanteric Bursitis What do you do when you have it? Initial Treatment Relative Rest Ice Anti- inflammatories Stretching

32 Trochanteric Bursitis Treatment: Medical Management ITB Massage/Mobilization Ultrasound Ice/Heat contrast Multi-planar strengthening Cortisone shot

33 Hip & Knee Pathology Treatment Thorough Assessment of: Biomechanical factors –Inflexibility –Strength –Endurance –Foot structure Training errors

34 Hip & Knee Pathology Treatment Gluteal strengthening in multiple planes Functional strengthening, control “track” Bracing as needed Quadriceps strengthening Gradual return to running Avoid running hills & stair climbing

35 Hip & Knee Pathology Treatment Strengthening hip & knee stabilizing muscles in multiple angles –single leg squats- emphasis knee mechanics and lumbar spine position- pelvic stability –stair pelvic drop- emphasis on lumbar spine position

36 Gluteal Strengthening “The Matrix”

37 “Power Runner” Gluteal Strengthening & Balance – Exercises that Mimic Function

38 Hip & Knee Pathology Alternate Exercise Options Cross training with: Low-resistance cycling or spinning Swimming Pool running Elliptical

39 Hip & Knee Pathology How to prevent its reoccurrence? Maintain multiplanar functional gluteal strength – “The Matrix” in routine workout 1-2x/week Preserve flexibility, especially quadriceps Slow, progressive return to activity Rely on gluteal muscles more than quadriceps for stair climbing and squatting Continue cross-training

40 Foot & Ankle Pathology

41 Plantar Fasciitis Common cause of heel pain Pain in the arch or near heel on bottom of foot Worst with 1 st am step

42 Plantar Fasciitis Causes High arched and “flat feet” Tight plantar fascia Tight & weak calf muscles Tight hip flexors Increase in mileage Increase in weight Inadequate shock absorption of the heel (shoe wear!)

43 Plantar Fasciitis What do you do if you have it? Ice (water bottle) Anti-inflammatories Golf/tennis ball massage Resting night splint, Ace wrap High top shoes or hiking boots Orthoses/Heel cups/Taping Injection

44 AchillesTendonitis If Chronic then called Tendonopathy Pain in back of heel Bump present? Pain with push-off

45 AchillesTendonitis AchillesTendonitis Causes Increased activity level &/or less recovery time Overpronation Tight hamstrings and heel cords High arched feet Weak calves Frequently wearing high heels

46 Achilles Tendonitis What do you do when you have it? Relative rest Anti-inflammatoriesIce Short term immobilization (splinting or bracing) Stretching Eccentric or Negative strengthening Heel lifts

47 Treatment Foot & Ankle Pathology Treatment Improve lower limb flexibility, especially calves Multi-planar balance exercises –Single Leg Stance Static Hold Dynamic Reaches Foot & toe strengthening –Towel Scrunching

48 Calf Stretching & Strengthening

49 Calf Stretch & Strengthening “Stomp the Bug”

50 “Shin Splints” (Medial Tibial Stress Syndrome) Pain located on the front or inside of shin Overuse tendonitis of posterior/anterior tibialis, soleus muscles

51 “Shin Splints” Causes Overpronation during gait cycle Rigid foot Weak lower leg muscles Increase of mileage, speed or new runner Improper shoe wear

52 “Shin Splints” What else could it be? –Stress reaction of bone –Stress fracture of tibia bone –Referred pain from knee or spine –Compartment syndrome

53 “Shin Splints” Treatment Relative rest Crutches if pain is present at rest or with normal walking IcingStretching Return to activity gradually (after pain free period) –Training should start at 50% of pre- injury distance and intensity –Soft, level surfaces Orthotics (to correct overpronation) Surgery (in resistant cases)

54 Stress Fractures Distance (>20Miles/week) Usually worse with activity – Worse as run progresses Better with rest Potential for devastating injury Can occur in hip, thigh, or shin

55 Stress Fractures Examination Bony tenderness Common areas- shins, hips, feet, thigh, pelvis X-Rays notoriously negative MRI/Bone Scan better test

56 Stress Fractures Treatment Depends on location –Likely immobilization or bracing Most heal with relative rest –cross train/water running/swim Some require surgical intervention

57 Pain does not go away during the run Hurts every step of the run Hurts even when walking Hurts with single leg hop If you have risk factors: eating disorder, poor calcium diet, prior stress fractures, female, osteoporosis in the family Stress Fractures Recognize the Symptoms

58 –Simple rest and ice is not alleviating your pain –You are unable to train at the intensity you desire –You are limited in your day to day activities because of your pain –Joint swelling is your body telling you something is wrong; this should be medically evaluated –We all get aches and pains with running, but if your pain is persistent, this should be medically evaluated Running Injuries WHEN TO SEE THE DOCTOR:

59 Fluid Intake

60 Facts Water composes % body weight Typical water intake is 2.4L/day Requirements vary depending on temp, humidity, activity Water deficits of 5-7% are assoc w/ dyspnea, HA, and apathy

61 Facts Sweat rate is approximately cc/hr in athletes Athletes typically consume only half of fluid losses Leads to ~3% (2-3lbs) weight loss in 4 hours

62 Water Requirements Lose 2-5% weight during moderately intense activity- roughly 1.5 L Typical sweat rates 1L/hr Theoretically, dehydration risk factor for heat illness

63 Consequences of water imbalance If deficit exceeds 2%, performance compromised Increase 1 ºC body temp for each 1% body weight loss Overhydration no benefit-possibly detrimental

64 Electrolytes Sweat is hypotonic Sodium generally meq/L As sweat rate increases, concentration of sodium increases AND----- with heat acclimatization sweat rate increases. Hence theoretical increased salt losses

65 Electrolytes Salt supplements do not improve performance or heat tolerance Cramps felt to be related to electrolytes but never proven Currently sodium supplementation not recommended-GI discomfort

66 Hydration Sweating rate is approximately cc/hr in runners 500cc fluid before exercising, 300cc every 20 minutes evidence to suggest that consumption of a low carbohydrate drink during prolonged and intermittent exercise will improve performance (No one type is superior to the other)

67 Sport drink comparison

68 Recommendations If exercising less than 50 minute, benefits of drinking questionable Heat injury may be more related to intensity of exercise Recommendations of fluid intake more for those athletes participating longer than 1 hour Supplemental salt intake if greater than 4 hours activity

69 Recommendations If activity less than 90 minutes, use water But 6-8% CHO has been shown to sustain better power output after 60 minutes, so it may improve performance particularly if no other nourishment Plus sports drinks may taste better

70 Running Injuries Conclusion Proper diagnosis of injury Understand goals Treat underlying cause Treat kinetic chain Be sport specific Make sense, be functional

71 “If I knew that I was going to live this long, I would have taken better care of myself” -Mickey Mantle


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