1. Evaluating Running Injuries in Clinic
Jim Chesnutt, M.D.
OHSU Sports Medicine Program
OHSU Orthopaedics and Rehabilitation
and Family Medicine

2. Common Running Injuries
Look at biomechanics of running
Consider factors leading to overuse injury
Identify common running injuries
Learn treatment and prevention strategies

3. Biomechanics of Running
1000 steps per mile
load is 2-3x body weight per stride
running shoes absorb shock but need new shoes each miles
shoes: cushion, support, traction
biomechanical abnormalities translate forces up and down kinetic chain
Pelvis-hip-knee-ankle-foot

4. Biomechanics of Running
The Two Phases of Gait
I. Support Phase- shock absorption
1. contact stage (25%)
-hip extended, knee flexed, foot supinated
2. midstance stage (50%)
-rapid pronation, shock absorption
3. take-off stage (25%)
-supinated, rigid foot, contracted gastrocs
II. Recovery Phase-
airborne swing

5. Common Overuse Syndromes
Mechanisms of Injury
1. repetitive motion/ stress
2. microtrauma
3. stress or trauma >> adaptation or repair
4. chronic or progressive pain and dysfxn or mechanical failure (macrotrauma)
5. phases of healing : I. inflammatory( 1-5 days)
II. regeneration( days)
III. remodeling( 14+ days)

6. Common Overuse Syndromes
Stages
1 : pain after activity only
2 : pain during activity but not affecting performance
3 : pain during activity causing restricted performance
4 : chronic pain, even at rest

7. Common Overuse Syndromes
Factors
A. Intrinsic
1. Anatomical malalignment or defect
- e.g. flat foot, osteoporosis
2. Biomechanical dysfxn
- e.g. tibial torsion, over-pronation,
inflexibility, muscle imbalance

8. Common Overuse Syndromes
Factors
B. Extrinsic
1. Activity- related functional overload
- e.g. improper technique and training errors ( too fast, too long, too many)
2. Poor equipment or environment
- e.g. inadequate support or shock absorption or surface too hard

9. Overuse Injuries: 5 Step Treatment
Overuse Injuries: 5 Step Treatment (O’Connor FG et al, Phys and Sports Med 1992 ;21(7): )
Patho-anatomic Diagnosis (First step)
A. Principle of Transition(Leadbetter)
Hx: change in mode or use of involved part
B. Principle of “victims ( injured site) and culprits(primary dysfunction)”(Macintyre)
PE: biomechanical exam to find injury/cause

10. Running Injuries Risks: 1) >40 miles/ wk 2) previous injury
3) >10% increase mileage per wk
4) foot, knee, and hip malalignment
(hyper-pronation, weak hip flexor)

11. Common Running Injuries
Most common:
1) Patellofemoral Pain Syndrome
2) Medial Tibial Stress Syndrome
(“shin splints”)
3) Iliotibial Band Friction Syndrome
4) Plantar Fasciitis
5) Achilles’ Tendinitis

12. Common Running Injuries
6. Stress Fracture of Tibia 7. Stress Fracture of Femur 8. Exertional Compartment Syndrome 9. Female Athlete Triad 10. Iron Deficiency

13. Patellofemoral Pain Syndrome
Combination of various syndromes including patellar subluxation, pain and “chondromalacia”
More common in females
Classical anterior knee pain, crepitance, and occ. swelling as well as “positive theater sign”

14. Patellofemoral Pain Syndrome
Anatomical Predisposing Factors
wide pelvis
femoral anteversion
tight hamstrings***
weak vastus medialis obliques( VMO)**
weak hip flexor and abductors***
over-pronation of foot***
externally rotated tibia
lateral tib tubercle (large “Q- angle”)
lateral patella (subluxable)

15. Runner’s Exam Inspect fro atrophy/ effusion/red Squat double leg
Squat single leg
Sitting extension
Knee ligament meniscus exam
Hamstring flexibility
Ober’s Test: tight ITB or hip flexor
Hip abduction resistance

21. Patellofemoral Pain Syndrome
Treatment
modify activity ( less flexion stress)
ice and NSAIDs (+/-)
bracing or taping (+/-), chopat strap
strengthen VMO and hip flexor/abductor
stretch hamstrings
orthotics
surgery (rare)

22. Iliotibial Band Syndrome
lateral knee pain during flexion( 30deg)
worse with banked or downhill running
over-pronation with int. tibial rotation
ITB tightness--pos. Ober test***
RX: NSAIDs (1 wk) or steroid injection
stretch, ice, friction rub, US
fix pronation(orthotic) or hip mobility

23. “Shin Splints” Exercise- related lower leg pain syndromes
Medial Tibial Stress Syndrome
pain medial-posterior tibia diffusely
soleus insertion periostitis
plantar flexor and invertor
x-ray: neg or diffuse periosteal reaction
bone scan: diffuse late- phase only

24. Medial Tibial Stress Syndrome
Factors
runner, hard surface, poor cushion
poor conditioning, sudden increased intensity and duration ( > 10% per week)
excessive and rapid pronation, tight Achilles

25. Medial Tibial Stress Syndrome Treatment
relative rest
(5-7d)
ice massage
NSAIDs
Achilles stretch
better shoes
medial stabilizer
cushioning
not surgery

26. Lateral Tibial Periostitis
pain lat-ant tibia diffusely
tibialis anterior insertion
dorsiflexor, evertor
x-ray/ bone scan : same
factors:
tight Achilles***
increased hills/dorsiflexion
Rx: same

27. Exertional Compartment Syndrome
pain increases with activity
resolves after rest, not immediate
no bone pain
muscle herniation is diagnostic
elevated compartment pressure(>30mm hg)
anterior %
deep posterior 20-30%
all others 20%
factors: non-traumatic, unknown
Rx: fasciotomy or limit activity

28. Nerve and Vascular Entrapment
Peroneal Nerve
Lateral post knee pain
Lateral calf / foot pain and numbness
Peroneal weakness and foot drop
Posterior Tibial Artery
Compressed in the popliteal region
May be positional
May cause pain and numbness

29. Tibial Stress Fracture
focal tibial pain (esp with 3 pt bending)
medial or lateral (different types)
bending force from muscle tension
tension: ant-lat, mid
compression: post-med, distal/ prox
pain despite rest/ treatment for 2 wks

30. Tibial Stress Fracture
xray:
medial: focal periosteal thickening (post-med)
lateral: “dreaded black line” fracture (ant-lat)
bone scan: focal uptake( all phases)
positive 3-5d post pain increase
key study to diagnose

31. Imaging in Stress Fracture
bone scan: ( $500)
focal uptake( all phases)
positive 3-5d post pain increase
key study to diagnose
Sensitive but not specific
MRI: ( $1500+)
Early-( 1-3 days) focal T2 increase signal in area of edema in marrow and bone
Later- low T1 signal indicates feacture line
Sensitive and specific and anatomic detail

32. Tibial Stress Fracture
Factors
hard surface, poor shoes
anatomical malalignment
foot pronation
leg length, rotation, or hip problem
abrupt training increase
osteoporosis
jumping sports (esp ant-lat tibia fx )

33. Tibial Stress Fracture
Ant-lateral: caution!!
higher rate nonunion
20% to full fx
average 1 yr off sport
consider bone stimulator, IM rod
Medial:
more common
heals with 4-6 wks rest, slow progress
**Often bilateral and recurrent**

34. Tibial Stress Fracture
Treatment
improve shock absorbing or reduce stress
- shoes , surface, rest, modified activity
long air casts
orthotic
augment bone healing
No NSAIDs
calcium 1200 mg/day
estrogen status/eating disorder/ osteoporosis

35. Orthotics Have been shown to treat 75% of injured runners successfully
Mechanism: limitation of abnormal pronation and subtalar motion
Off -the -shelf models can be as effective, less costly as custom

36. Stress Fractures Incidence: track( 13-52%)- tibia, navic
ballet( 22-45%)- MT, fibula
Most common sites: tibia( 30-50%), fibula, metatarsal, femur, tarsal (navicular).
Female > male by 3-10x
High risk in amenorrhea, high mileage
37% of college women, 50% amenorrheic
- Female Athlete Triad
-anorexia, amenorrhea, osteoporosis

37. Female Athlete Triad Low energy balance/ Eating disorder Amenorhea
Overtraining
Undereating of calories
Amenorhea
Fewer that 4 menstrual periods/ yr
Osteoporosis

38. Low Iron: Runners Anemia
Runners consume more iron that general public
Low iron effects performance
Screen females/?men with ferritin
Level above is probably best
Iron is best taken as food items: meats, fish, legumes, greens, tofu, eggs ,nuts, dried fruits
Supplement if low: caution for overload

39. High Risk Stress Fractures
Femoral neck
Anterior cortex tibia
Tarsal navicular
Base of 5th metatarsal
-Often delay in diagnosis
-Poor outcomes if not treated with proper immolization and non-wt bearing

40. Femoral Neck Stress Fractures
Vague anterior thigh or groin pain
Pain with extreme IR/ER or hopping on leg
Average 3 month delay in diagnosis, AVN risk
Lateral -superior, tension side -- serious
Medial, compression---less serious
MRI superior to bone scan
1: edema only
2: fracture line less than 50%
3: fracture line > 50%

41. Femoral Neck Stress Fractures
Non-wt bearing until asymptomatic
Usually 4-8 weeks initially
Progressive functional rehabilitation
Re image if not progressing as expected
Refer to orthopaedic surgeon if fracture line is >50% to consider immediate pinning

42. Stress Fractures Healing- average 3-6 weeks
2 wks: metatarsal and fibula
6-8 wks: most other bones
4+ months: anterior tibia, navicular, Jones fx
Localized SF heals 2x rate of complete SF
Recurrence: 50% overall (13% at 1yr)

43. Plantar Fasciitis most common cause of heal pain
medial calcaneal tubercle, origin of central band of plantar fascia
painful first step of the morning
relieved with exercise, pain resting
no pain with lateral compression
xray rarely useful, spur irrelevant

44. Plantar Fasciitis Factors excess pronation or high, rigid arch
women > men
overweight and/or overtraining
poor arch support or cushion
tight heel cords

45. Plantar Fasciitis Treatment modify activity and weight
orthotics, arch support, or heel cups
ice and NSAIDs
stretch Achilles and calves
cortisone shot (caution fat pad atrophy)
nite splints (83% effective if used right)

46. Achilles Tendinitis 15% of all running injuries mostly males
Achilles takes highest force in the body- up to 8x body wt , running
combined gastrocs and soleus
occurs 2-6 cm above calcaneus at site of low blood flow
usually tendinosis when chronic

47. Achilles Tendinitis Factors 1. poor body mechanics
- poor flexibility or alignment
2. training errors
3. environmental factors
4. athletic shoes

48. Achilles Tendinitis Treatment Physical therapy
specialized stretch program
ice and/or ultrasound
NSAIDs but no cortisone injections
Orthotics and initial heel lift
Surgery- 90% to full activity and 75% to high level

49. Running Shoe Prescription
Evaluate shoe wear pattern and foot type
Rigid foot
Normal foot
Floppy Foot
Shoe type

50. Running Shoes Rigid foot: lateral tilt and wear Cushion shoe
Normal foot: lateral heal strike with minimal excess motion
Stability shoes
Floppy foot: rolls to midline with wt bearing; medial tilt and wear pattern
Motion control shoe, anti-pronation
Goal: Happy Feet = Happy Runner

51. References
Asplund C, Brown D. The Running Shoe Presciption. The Phys and Sportsmed. Vol. 33 (1), Jan 2005.
Cole C, Seto C, Gazewood J. Plantar Fasciitis: Evidenced-Based Review of Diagnosis and Therapy. Am Fam Phys. , Vol 72 ( 11), Dec 2005.
Hreljac A. Impact and Overuse Injuries in Runners. Med Sc in Sports & Exercise. Vol 36 (5), 2004.
Hurwitz S. Athletic Foot and Ankle Injuries. Clinics in Sports Medicine. Vol 23 (1), Jan 2004.

52. References
Kennedy J, et al. Foot and ankle injuries in the adolescent runner. Current Opinion in Pediatrics. Vol 17,2005.
Lun V, Meeuwisse WH, et al. Relation between running injury and static lower limb alignment in recreational runners. Br. J. Sports Med. Vol 38, 2004.
Mellion M,et al. The Team Physician’s Handbook, 2nd ed. Hanley and Belfus
Niemuth P et al. Hip Muscle Weakness and Overuse Injuries in Recreational Runners. Clin J Sports Med. Vol 15 (1), Jan 2005.