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
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 (“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)
Haglund’s

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.