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Irene S. Davis, PhD, PT, FACSM, FAPTA, FASB

Dept. PM&R, Harvard Medical School Director, Spaulding National Running Center

Running Injury Mechanics

Distribution of Running Injuries

knee

foot

ankle lower leg

thigh

hip back

Patellofemoral Pain Syndrome

Iliotibial Band Syndrome

Achilles Tendinitis

Tibial Stress Syndrome/ Fractures

Plantar Fasciitis

Compartment Syndrome Posterior Tib Tendinitis

FAI/Labral Tears

Femoral Neck Fx

Hamstring Strains

Metarsalgia/Stress Fx

Taunton et al, 2001

1. Patellofemoral Pain Syndrome

Incidence Most common injury in runners 2X more common in females 25% of all knee related issues Suggested it may be on a continuum of PFJ

OA Presentation Retro and peripatellar pain associated with

knee flexion on a loaded knee Squatting Running Stairs

* EV

*

ABD

*

FL

!

*IR

Excessive Pronation

Doesn’t explain association of pronation and PFJ Pain

Apparent Paradox

Eversion = Tibial IR

Q Angle

Effect of Pronation on the PFJ : A Theoretical Model

Tiberio, 1987

Femur IR TFJ ER Q Angle

Potential Solution

Timing Issue ?

…….but if: Prolonged EV Prolonged TIR

As the Knee extends, it needs TER

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Hewett, 2002

Valgus Varus 0

10 20

30 40 50 60

70 80 Female

Male

Perc

ent

*

*

Single Leg Squat

Gender Differences in Movement Gender Differences - Running

Hip ADD Hip IR

Knee ABD (val) Foot EV

Hip ABD Hip ER

Knee ADD (var) Foot INV

Mechanics of PFPS (females)

0

4

8

12

16

20

* *

Hip ER Hip ABD

Isometric Strength (kg)

Control PFPS PFPS Weaker

4 8

12 16

25 50 75 100 Hip ADD angle (deg)

PFPS

Control

ADD

ABD

Inc. Hip ADD

Willson et al, 2008

-3

0

3

25 50 75 100

Pelvic drop angle (deg) Control

PFPS DN

UP

Inc pelvic drop

-14

-10

-6

-2

2

6

25 50 75 100

Knee IR angle (deg)

Control

PFPS

IR

ER

Inc Knee ER

Mechanics of PFPS (females)

15 PFP

15 CON

Prior studies have been cross-sectional or retrospective A word about males (who also get PFP)

Healthy male Male with PFPS Female with PFPS

Willy et al, 2012

Inc. CPD, KADD Inc. CPD, HADD

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But not purely a sex difference

HADD KADD

F-PFP M-PFP Ind. Female Ind. Male

HADD 3/18 M-PFP similar to F-PFP 4/18 F-PFP similar to M-PFP

KADD (Varus) 3/18 M-PFP similar to F-PFP 4/18 F-PFP similar to M-PFP

Willy et al, 2012

15-20% demonstrate the opposite sex mechanics

Effect of Tibiofemoral Angle on PFJ

Articular shear, Hydrostatic pressures

Huberti and Hayes, 1984, Lee et al., 2003, Besier et al., 2008

Lat Med

MALES FEMALES

Impact Loading

Impact Peak

Load rate

Bowser and Davis, 2010

PFPS – Associated with High Impacts! 2. Iliotibial Band Syndrome

Incidence 2nd Most common injury in runners Most common injury of the lateral knee 2X more common in females Presentation Pain at distal lateral knee Often comes on with downhill running

Iliotibial Band Syndrome

Running downhill

No diff in Knee Flex (Orchard 1996)

ITB moves posteriorly Creates friction

Iliotibial Band Syndrome

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Iliotibial Band Syndrome

HADD kIR

Cross-over

Iliotibial Band Syndrome

Prospective (17 ITBS, 17 con)

ITBS 4.4 deg Con 0.0 deg p=0.002

-8-6-4-2024

0 20 40 60 80 100

% of Stance

An

gle (D

eg

)

ITBS Control

Knee IR

ITBS 1.8 deg Con -1.2 deg p=0.027

Retrospective (35 ITBS, 35 con) Knee Internal Rotation

-12

-10

-8

-6

-4

-2

0

2

0 20 40 60 80 100

% of Stance

An

gle

(D

eg

)

ITBS Control

Knee IR

Iliotibial Band Syndrome

ITBS 10.4 deg Con 7.9deg p=0.049

Retrospective (35 ITBS, 35 con)

Knee IR

Hip Adduction

-2

0

2

4

6

8

10

0 20 40 60 80 100

% of Stance

An

gle

(D

eg

)

ITBS Control

Hip Add

Prospective (17 ITBS, 17 con)

ITBS 14.1 deg Con 10.6 deg p=0.018

Knee IR

02468

101214

0 20 40 60 80 100

% of Stance

An

gle (D

eg

)

ITBS Control

Hip Add

3. Hamstring Strain

Incidence 8-25% in general sporting population

Definition Strain of the Hamstring Muscle

Mid-substance Insertional

Hamstring Strain

Overstriding Pelvic Instability

4. Stress Fractures

Incidence 5-30 % of athletes and military recruits

Females more likely Tibia most common site

Definition A crack in the bone from repeated

mechanical stress

Bone resorption > Bone deposition

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Stress Fractures

Clinical Presentation Focal Pain with loading

Differential DX Stress Fracture

DVT Nerve Entrapment

Tumor

Stress Fractures

Tibial

Structural

Low area moments of inertia Long thin bones: lower resistance to bending

Stress Fractures

Tibial Impact Peak

Load rate

Tibial Shock

Biomechanical High Impact

Loading

Stress Fractures

Tibial

Biomechanical

Increased Hip ADD RF EV

Free Momwnt

Stress Fractures

Femoral Biomechanical

Excessive stride length

Stress Fractures

Metatarsal

Structural

Long thin bones Weak feet

High Arch Low Arch

Biomechanical

High Impact Loading Low Arch/Eversion High Arch/Inversion

Forefoot Striker

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Incidence 14% of those with unknown

lower leg pain

Definition Elevated Pressures in one of the lower leg compartments due to increased blood flow

and/or hypertropy

Anterior Lateral

Superficial Posterior Deep Posterior

Qvarfordt et al, 1983

5. Compartment Syndrome Compartment Syndrome

Clinical Presentation Aching, cramping, burning

Tightness – rock hard Numbness Foot drop

Differential DX Stress Fracture

DVT Nerve Entrapment

Tumor

Structural Causes Tight fascia

Muscle Hypertrophy

Compartment Syndrome

Overtraining Overstriding

Compartment Syndrome

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7. Posterior Tibialis Tendinitis

Incidence More common in Females More common in flat feet

Definition Inflammation of the Posterior Tibialis tendon

Stage 1 PTTD?

Posterior Tibialis Tendinitis

Clinical Presentation Pain behind medial malleolus

Pain in medial arch Worsens with activity

Differential DX Flex Dig Longus Flex Hall Longus Spring lig sprain

Posterior Tibialis Tendinitis

Structural

Pes planus (limited DF)

Posterior Tibialis Tendinitis

Excessive EV (RF or MF) Cross-over Gait

Toe-out

8. Achilles Tendinitis

Incidence 24% Lifetime incidence

40-50% Lifetime incidence in runners

Definition Inflammation of the Achilles tendon

Midsubstance Insertional

Presents as am pain and stiffness in tendon

Achilles Tendinitis

Forefoot Striker High Arch Low Arch

Excessive Eversion

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9. Plantar Fasciitis

Incidence 10% of population will experience Most common cause of heel pain

Females 2X more likely

Definition Inflammation of the plantar fascia – a ligament

on the plantar surface of the foot

Plantar Fasciitis

Clinical Presentation Heel pain on first morning step

Can extend the length of the PF Loosens up when you run

Then begins to get sore at end of run or after

Differential DX Fat Pad Atrophy

Tarsal Tunnel Syndrome Calcaneal Stress Fx

Flex Dig Brev tendinits

Repetitive Traction Injury Plantar Fasciitis

High Arch Low Arch

Structure

Williams et al, 2000 P0hh et al, 2000

Limited DF Weak Calf

Plantar Fasciitis

Mechanics

Excessive Rearfoot Pronation

Excessive Midfoot Pronation

Plantar Fasciitis

Cross-over Toe-out

Other factors: Age, BMI, Activity level

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Plantar Fasciitis

Plantar Fasciitis group had greater vertical ground reaction force load rates than age and mileage matched controls

Pohl et al, 2009

10. FAI/Labral Tear

HADD and HIR

Females – Pincer Males - Cam

Low Back Pain

Pronation Supination Cross-over

Anything that causes gait asymmetry

High impact loading