Common Running Injuries: Prevention & Rehabilitation Shana Margolis, MD Attending Physician,...
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Transcript of Common Running Injuries: Prevention & Rehabilitation Shana Margolis, MD Attending Physician,...
Common Running Injuries: Common Running Injuries: Prevention & RehabilitationPrevention & Rehabilitation
Shana Margolis, MDShana Margolis, MDAttending Physician, Rehabilitation Institute of ChicagoAttending Physician, Rehabilitation Institute of ChicagoClinical Instructor, Northwestern Feinberg School of Clinical Instructor, Northwestern Feinberg School of
MedicineMedicine
Davalyn Partain, PT, DPTDavalyn Partain, PT, DPTPhysical Therapist, Department of Orthopaedic Physical Therapist, Department of Orthopaedic
Surgery, Northwestern Medical Faculty Foundation, Surgery, Northwestern Medical Faculty Foundation, Rehabilitation Institute of ChicagoRehabilitation Institute of Chicago
June 16, 2010June 16, 2010
AcknowledgementsAcknowledgementsChristopher Plastaras, MDChristopher Plastaras, MDJoseph Ihm, MDJoseph Ihm, MDPaul Lento, MDPaul Lento, MDJo Fasen, PT, MPT, OCS, CSCS, Cert. MDTJo Fasen, PT, MPT, OCS, CSCS, Cert. MDT
What is Physiatry?What is Physiatry?Also called physiatrists Also called physiatrists
(fizz ee AT’ trists) (fizz ee AT’ trists)
Physical Medicine & Physical Medicine & RehabilitationRehabilitation
““Physicians of Function”Physicians of Function”
4 year residency program4 year residency program
Evaluation and Treatment of Evaluation and Treatment of all disabilitiesall disabilities
Musculoskeletal and Sports Musculoskeletal and Sports medicine is one aspectmedicine is one aspect
Musculoskeletal Healthcare Musculoskeletal Healthcare ProviProvidersders
Orthopedic Surgeons Orthopedic Surgeons and Podiatristsand Podiatrists– Operate on bones, Operate on bones,
tendons, ligamentstendons, ligaments
Types of Physicians:Types of Physicians:Physical Medicine & Physical Medicine & Rehabilitation Rehabilitation (Physiatrists)(Physiatrists)– Non-operative Non-operative
care of care of musculoskeletal musculoskeletal problemsproblems
Physical Physical Therapists & Therapists & Occupational Occupational TherapistsTherapists– Specialize in Specialize in
designing designing exercises for exercises for muscle, bone, muscle, bone, nerve problemsnerve problems
Athletic Trainers, Athletic Trainers, Physical Therapists Physical Therapists Assistants & AidsAssistants & Aids– Work closely with Work closely with
physical therapists to physical therapists to instruct on proper instruct on proper exercise techniqueexercise technique
Running Coaches, Running Coaches, Personal Trainers, Personal Trainers, Pilates/Yoga Pilates/Yoga InstructorsInstructors– Advance Advance
physical fitness physical fitness in people in people without without pathology or pathology or painpain
PhysiciansPhysicians– DiagnoseDiagnose– Order testsOrder tests– Prescribe MedsPrescribe Meds– Prescribe therapyPrescribe therapy– Prescribe Prescribe
interventions interventions (injections/surgery)(injections/surgery)
ChiropractorsChiropractors– Specialize in Specialize in
manual manual assessment and assessment and treatment of treatment of musculoskeletal musculoskeletal problemsproblems
PedorthotistPedorthotist – Make & advise Make & advise
orthotic orthotic devices, shoes, devices, shoes, bracesbraces
What is running?What is running?
One leg hoppingOne leg hopping
Leg absorbs forceLeg absorbs force
Requires flexibilityRequires flexibility
Requires hip girdle Requires hip girdle strengthstrength
Lengthening Lengthening ContractionContraction– Most damaging to muscle Most damaging to muscle
and requires great and requires great strengthstrength
– Fatigue?Fatigue?
Running Injury PreventionRunning Injury Prevention
Injury Risk FactorsInjury Risk FactorsExtrinsic Extrinsic factorsfactors– Training errorsTraining errors– EquipmentEquipment
Shoe typeShoe typeShoe ageShoe age
– EnvironmentEnvironmentSurface typeSurface typeCamberCamberDirectionDirection
Intrinsic factorsIntrinsic factors– Bone alignmentBone alignment– Muscle imbalanceMuscle imbalance– Biomechanical deficitsBiomechanical deficits
Kinetic Chain Kinetic Chain FocusFocus
Proximal segments can Proximal segments can influence distal influence distal segment motionsegment motion
Distal segments can Distal segments can influence proximal influence proximal segment motionsegment 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
Causes of InjuryCauses of Injury
Trauma (less common)Trauma (less common)
OveruseOveruse– ““Too Much Too Soon Too Too Much Too Soon Too
Fast”Fast”– Asymmetries Asymmetries
Previous injury Previous injury
Inflexibility/strength Inflexibility/strength differencesdifferences
Terrain (cambered/hills)Terrain (cambered/hills)
Training ErrorsTraining Errorstoo much, too soon, too fasttoo much, too soon, too fastIncreased injury rate beyond 20 Increased injury rate beyond 20 miles/weekmiles/week
Inadequate warm-upInadequate warm-up
Inadequate flexibility and strengthInadequate flexibility and strength
Inadequate rest between runsInadequate rest between runs
Too many miles, too soonToo many miles, too soon
Too much interval/speed trainingToo much interval/speed training
Running InjuriesRunning Injuries
Proper diagnosis of injuryProper diagnosis of injury
Understand goalsUnderstand goals
Treat underlying causeTreat underlying cause
Treat kinetic chainTreat kinetic chain
Make sense, be functionalMake sense, be functional
Injury EvaluationInjury Evaluation
History of History of problemproblemBiomechanical Biomechanical evaluationevaluationSite-specific Site-specific evaluationevaluationRunning Running assessmentassessmentShoe Shoe assessmentassessment
Common Injuries/ProblemsCommon Injuries/Problems
Hips/KneesHips/Knees– Patellofemoral PainPatellofemoral Pain– Iliotibial Band PainIliotibial Band Pain– Greater Trochanteric Greater Trochanteric
BursitisBursitisFeet/AnklesFeet/Ankles– Plantar FasciitisPlantar Fasciitis– Achilles tendonitisAchilles tendonitis““Shin Splints”Shin Splints”Stress Stress Reaction/FracturesReaction/FracturesHydrationHydration
Hip & Knee Pathology
Patellofemoral Pain Patellofemoral Pain ““Runner’s Knee”Runner’s Knee”
Pain located Pain located beneath and/or beneath and/or around knee caparound knee cap
Softening and Softening and compression of compression of cartilage under the cartilage under the knee capknee cap
>25% incidence in >25% incidence in athletesathletes
Females > MalesFemales > Males
Patellofemoral PainPatellofemoral PainVague, achy pain Vague, achy pain in front part of in front part of kneeknee
Worse with going Worse with going downstairsdownstairs
Pain when knee Pain when knee bent for long time bent for long time (like in the movie (like in the movie theatre)theatre)
Worse with hillsWorse with hills
Careful physical examinationCareful physical examination
Biomechanical evaluationBiomechanical evaluation
Running gait evaluation Running gait evaluation
X-rays usually normal in X-rays usually normal in mild/early casesmild/early cases
MRI if not getting better MRI if not getting better
Patellofemoral PainPatellofemoral PainEvaluationEvaluation
Understanding FunctionUnderstanding FunctionAbnormal knee cap tracking, abnormal alignmentKnee cap runs on femur “like train on tracks”
Patellofemoral PainPatellofemoral PainCausesCauses
Weak hip and core Weak hip and core muscles cause knee muscles cause knee cap to track improperlycap to track improperly
Tight quadricepsTight quadriceps
Overpronation of the Overpronation of the footfoot
Rigid footRigid foot
Patellofemoral PainPatellofemoral PainWhat do you do when you have it?What do you do when you have it?
Initial Treatment “PRICE”Initial Treatment “PRICE”
PProtectionrotection
RRelative Rest (& Gentle elative Rest (& Gentle Mobility)Mobility)
IIcece
CCompressionompression
EElevationlevation
Patellofemoral PainPatellofemoral Pain What do you do when you have it?What do you do when you have it?
Training modificationTraining modification
Knee bracing as Knee bracing as prescribedprescribed
Patellar mobilization, Patellar mobilization, manual therapymanual therapy
Ice regularlyIce regularly
Patellofemoral PainPatellofemoral PainWhat do you do when you have it?What do you do when you have it?
Patellar taping: a Patellar taping: a transitional steptransitional step– to encourage more force to encourage more force
from quadriceps, help from quadriceps, help with painwith pain
Flexibility: ITB, hip Flexibility: ITB, hip flexors, hamstrings, flexors, hamstrings, quadriceps, calfquadriceps, calf– Quadriceps flexibility- Quadriceps flexibility-
emphasis on lower back emphasis on lower back positionposition
Patellofemoral Patellofemoral PainPain
Additional remedies Additional remedies known to work!known to work!
Chopart strapChopart strap
Quad and ITB MassageQuad and ITB Massage
Change shoesChange shoes– get the right type for get the right type for your your
footfoot
OrthoticsOrthotics
BalanceBalance
Iliotibial Band SyndromeIliotibial Band Syndrome
Localized Localized tenderness on the tenderness on the outside of the kneeoutside of the knee
Especially common Especially common when training for when training for longer distances longer distances ~runs over 18 ~runs over 18 milesmiles
Iliotibial Band SyndromeIliotibial Band Syndrome
ITB passes over outside of femur ITB passes over outside of femur bone bone Repetitive motion causes rubbing Repetitive motion causes rubbing and inflammationand inflammation– Most friction when knee is bent Most friction when knee is bent
20-30 degrees 20-30 degrees
Iliotibial Band SyndromeIliotibial Band SyndromeCausesCauses
Flat feet with no motion control shoesFlat feet with no motion control shoes
High arches with excessive supinationHigh arches with excessive supination
Due to hip girdle weakness and/or Due to hip girdle weakness and/or tightnesstightness
Leg length differenceLeg length difference
Banked terrain, hills & stairsBanked terrain, hills & stairs
Increased mileage?Increased mileage?
Iliotibial Band SyndromeIliotibial Band Syndrome What do you do when you have it?What do you do when you have it?
Initial Treatment “RICE”Initial Treatment “RICE”
RRelative Rest elative Rest
IIcece
CCompressionompression
EElevationlevation
Iliotibial Band SyndromeIliotibial Band Syndrome What do you do when you have it?What do you do when you have it?
Anti-inflammatoriesAnti-inflammatories
Soft tissue Soft tissue mobilization/massagemobilization/massage
Foam roll mobilizationFoam roll mobilization
UltrasoundUltrasound
StretchingStretching
Multi-planar Multi-planar strengtheningstrengthening
Motion control shoesMotion control shoes
Shorten stride lengthShorten stride length
Trochanteric BursitisTrochanteric Bursitis
Pain over outer hipPain over outer hip
May radiate down May radiate down outside of thighoutside of thigh
Back or deeper hip Back or deeper hip problem?problem?
Pain laying on sidePain laying on side
Increased frequency in Increased frequency in running or contact running or contact sportssports
Females>MalesFemales>Males
Trochanteric BursitisTrochanteric BursitisCausesCauses
Direct impact or fallDirect impact or fall
Repetitive friction of Repetitive friction of glut med or ITBglut med or ITB
Leg length Leg length discrepancydiscrepancy
Hip weaknessHip weakness
Lateral hip surgeryLateral hip surgery
Trochanteric BursitisTrochanteric Bursitis What do you do when you have it?What do you do when you have it?
Initial TreatmentInitial Treatment
Relative RestRelative Rest
Ice Ice
Anti-Anti-inflammatoriesinflammatories
StretchingStretching
Trochanteric BursitisTrochanteric BursitisTreatment: Medical ManagementTreatment: Medical Management
ITB Massage/MobilizationITB Massage/Mobilization
UltrasoundUltrasound
Ice/Heat contrast Ice/Heat contrast
Multi-planar strengtheningMulti-planar strengthening
Cortisone shotCortisone shot
Hip & Knee PathologyHip & Knee PathologyTreatmentTreatment
Thorough Assessment of:Thorough Assessment of:
Biomechanical Biomechanical factorsfactors– InflexibilityInflexibility– StrengthStrength– EnduranceEndurance– Foot structureFoot structure
Training errorsTraining errors
Hip & Knee PathologyHip & Knee PathologyTreatmentTreatment
Gluteal strengthening in Gluteal strengthening in multiple planesmultiple planesFunctional Functional strengthening, control strengthening, control “track”“track”Bracing as neededBracing as neededQuadriceps Quadriceps strengtheningstrengtheningGradual return to Gradual return to runningrunning
Avoid running hills & stair climbing
Hip & Knee PathologyHip & Knee PathologyTreatmentTreatment
Strengthening hip & knee stabilizing Strengthening hip & knee stabilizing muscles in multiple angles muscles in multiple angles – single leg squats- emphasis knee single leg squats- emphasis knee
mechanics and lumbar spine position- mechanics and lumbar spine position- pelvic stabilitypelvic stability
– stair pelvic drop- emphasis on lumbar stair pelvic drop- emphasis on lumbar spine positionspine position
Gluteal StrengtheningGluteal Strengthening
““The Matrix”The Matrix”
““Power Runner”Power Runner”
Gluteal Strengthening & Balance – Gluteal Strengthening & Balance – Exercises that Mimic FunctionExercises that Mimic Function
Hip & Knee PathologyHip & Knee PathologyAlternate Exercise OptionsAlternate Exercise Options
Cross training with:Cross training with:Low-resistance cycling or spinningSwimmingPool runningElliptical
Hip & Knee PathologyHip & Knee PathologyHow to prevent its reoccurrence?How to prevent its reoccurrence?Maintain multiplanar Maintain multiplanar functional gluteal strength – functional gluteal strength – “The Matrix” in routine “The Matrix” in routine workout 1-2x/weekworkout 1-2x/week
Preserve flexibility, Preserve flexibility, especially quadricepsespecially quadriceps
Slow, progressive return to Slow, progressive return to activityactivity
Rely on gluteal muscles Rely on gluteal muscles more than quadriceps for more than quadriceps for stair climbing and squattingstair climbing and squatting
Continue cross-trainingContinue cross-training
Foot & Ankle Pathology
Plantar FasciitisPlantar Fasciitis
Common cause Common cause of heel painof heel painPain in the arch Pain in the arch or near heel on or near heel on bottom of footbottom of footWorst with 1Worst with 1stst am stepam step
Plantar FasciitisPlantar FasciitisCausesCauses
High arched and “flat feet”High arched and “flat feet”Tight plantar fasciaTight plantar fasciaTight & weak calf musclesTight & weak calf musclesTight hip flexorsTight hip flexorsIncrease in mileageIncrease in mileageIncrease in weightIncrease in weightInadequate shock Inadequate shock absorption of the heel absorption of the heel (shoe wear!)(shoe wear!)
Plantar FasciitisPlantar FasciitisWhat do you do if you have it?What do you do if you have it?
Ice (water bottle)Ice (water bottle)
Anti-inflammatoriesAnti-inflammatories
Golf/tennis ball massageGolf/tennis ball massage
Resting night splint, Ace Resting night splint, Ace wrapwrap
High top shoes or hiking High top shoes or hiking bootsboots
Orthoses/Heel cups/TapingOrthoses/Heel cups/Taping
InjectionInjection
AchillesTendonitisAchillesTendonitis
If Chronic then called If Chronic then called TendonopathyTendonopathyPain in back of heelPain in back of heelBump present?Bump present?Pain with push-offPain with push-off
AchillesTendonitisAchillesTendonitis Causes
Increased activity level &/or Increased activity level &/or less recovery timeless recovery time
OverpronationOverpronation
Tight hamstrings and heel Tight hamstrings and heel cordscords
High arched feetHigh arched feet
Weak calvesWeak calves
Frequently wearing high heelsFrequently wearing high heels
Achilles Tendonitis Achilles Tendonitis What do you do when you have it?What do you do when you have it? Relative restRelative restAnti-inflammatoriesAnti-inflammatoriesIceIceShort term Short term immobilization immobilization (splinting or bracing)(splinting or bracing)StretchingStretchingEccentric or Negative Eccentric or Negative strengtheningstrengtheningHeel liftsHeel lifts
Foot & Ankle Pathology TreatmentTreatment
Improve lower limb flexibility, Improve lower limb flexibility, especially calvesespecially calves
Multi-planar balance exercisesMulti-planar balance exercises– Single Leg StanceSingle Leg Stance
Static HoldStatic Hold
Dynamic ReachesDynamic Reaches
Foot & toe strengtheningFoot & toe strengthening– Towel ScrunchingTowel Scrunching
Calf Stretching & StrengtheningCalf Stretching & Strengthening
Calf Stretch & StrengtheningCalf Stretch & Strengthening
““Stomp the Bug”Stomp the Bug”
““Shin Splints”Shin Splints”(Medial Tibial Stress Syndrome)(Medial Tibial Stress Syndrome)
Pain located on the Pain located on the front or inside of shinfront or inside of shin
Overuse tendonitis of Overuse tendonitis of posterior/anterior posterior/anterior tibialis, soleus musclestibialis, soleus muscles
““Shin Splints”Shin Splints”CausesCauses
Overpronation during gait Overpronation during gait cyclecycle
Rigid footRigid foot
Weak lower leg musclesWeak lower leg muscles
Increase of mileage, speed Increase of mileage, speed or new runneror new runner
Improper shoe wearImproper shoe wear
“Shin Splints”
What else could it be?What else could it be?– Stress reaction of boneStress reaction of bone– Stress fracture of tibia boneStress fracture of tibia bone– Referred pain from kneeReferred pain from knee
or spineor spine– Compartment syndromeCompartment syndrome
““Shin Splints”Shin Splints” TreatmentTreatment
Relative restRelative restCrutches if pain is present at rest Crutches if pain is present at rest or with normal walkingor with normal walkingIcingIcingStretchingStretchingReturn to activity gradually (after Return to activity gradually (after pain free period)pain free period)– Training should start at 50% of pre-Training should start at 50% of pre-
injury distance and intensityinjury distance and intensity– Soft, level surfacesSoft, level surfaces
Orthotics (to correct Orthotics (to correct overpronation)overpronation)Surgery (in resistant cases)Surgery (in resistant cases)
Stress FracturesStress Fractures
Distance Distance (>20Miles/week)(>20Miles/week)
Usually worse with Usually worse with activityactivity– Worse as run progressesWorse as run progresses
Better with restBetter with rest
Potential for devastating Potential for devastating injuryinjury
Can occur in hip, thigh, Can occur in hip, thigh, or shinor shin
Stress FracturesStress Fractures ExaminationExamination
Bony tendernessBony tenderness
Common areas-Common areas-shins, hips, feet, shins, hips, feet, thigh, pelvisthigh, pelvis
X-Rays notoriously X-Rays notoriously negative negative
MRI/Bone Scan MRI/Bone Scan better testbetter test
Stress FracturesStress FracturesTreatmentTreatment
Depends on locationDepends on location– Likely immobilization or Likely immobilization or
bracingbracing
Most heal with relative Most heal with relative restrest– cross train/water cross train/water
running/swimrunning/swim
Some require surgical Some require surgical interventionintervention
Pain does not go away during the runPain does not go away during the run
Hurts every step of the runHurts every step of the run
Hurts even when walkingHurts even when walking
Hurts with single leg hopHurts with single leg hop
If you have risk factors: eating If you have risk factors: eating disorder, poor calcium diet, prior disorder, poor calcium diet, prior stress fractures, female, osteoporosis stress fractures, female, osteoporosis in the familyin the family
Stress FracturesStress FracturesRecognize the SymptomsRecognize the Symptoms
– Simple rest and ice is not Simple rest and ice is not alleviating your painalleviating your pain
– You are unable to train at the You are unable to train at the intensity you desireintensity you desire
– You are limited in your day to You are limited in your day to day activities because of your day activities because of your painpain
– Joint swelling is your body Joint swelling is your body telling you something is wrong; telling you something is wrong; this should be medically this should be medically evaluatedevaluated
– We all get aches and pains with We all get aches and pains with running, but if your pain is running, but if your pain is persistent, this should be persistent, this should be medically evaluatedmedically evaluated
Running InjuriesRunning InjuriesWHEN TO SEE THE DOCTOR:WHEN TO SEE THE DOCTOR:
Fluid IntakeFluid Intake
FactsFacts
Water composes 50-Water composes 50-70% body weight70% body weight
Typical water intake is Typical water intake is 2.4L/day2.4L/day
Requirements vary Requirements vary depending on temp, depending on temp, humidity, activityhumidity, activity
Water deficits of 5-7% Water deficits of 5-7% are assoc w/ dyspnea, are assoc w/ dyspnea, HA, and apathyHA, and apathy
FactsFacts
Sweat rate is Sweat rate is approximately 500-approximately 500-2000cc/hr in athletes2000cc/hr in athletesAthletes typically Athletes typically consume only half of consume only half of fluid lossesfluid lossesLeads to ~3% (2-3lbs) Leads to ~3% (2-3lbs) weight loss in 4 hours weight loss in 4 hours
Water RequirementsWater Requirements
Lose 2-5% weight Lose 2-5% weight during moderately during moderately intense activity- intense activity- roughly 1.5 Lroughly 1.5 L
Typical sweat rates Typical sweat rates 1L/hr1L/hr
Theoretically, Theoretically, dehydration risk factor dehydration risk factor for heat illnessfor heat illness
Consequences of water Consequences of water imbalanceimbalance
If deficit exceeds 2%, If deficit exceeds 2%, performance performance compromisedcompromised
Increase 1 ºC body Increase 1 ºC body temp for each 1% body temp for each 1% body weight lossweight loss
Overhydration no Overhydration no benefit-possibly benefit-possibly detrimentaldetrimental
ElectrolytesElectrolytes
Sweat is hypotonicSweat is hypotonic
Sodium generally 10-Sodium generally 10-30meq/L30meq/L
As sweat rate As sweat rate increases, increases, concentration of concentration of sodium increasessodium increases
AND-----AND----- with heat with heat acclimatization sweat acclimatization sweat rate increases. rate increases.
Hence theoretical Hence theoretical increased salt lossesincreased salt losses
ElectrolytesElectrolytes
Salt supplements do Salt supplements do not improve not improve performance or heat performance or heat tolerancetoleranceCramps felt to be Cramps felt to be related to electrolytes related to electrolytes but never provenbut never provenCurrently sodium Currently sodium supplementation not supplementation not recommended-GI recommended-GI discomfortdiscomfort
HydrationHydration
Sweating rate is Sweating rate is approximately 500-2000cc/hr approximately 500-2000cc/hr in runnersin runners
500cc fluid before exercising, 500cc fluid before exercising, 300cc every 20 minutes300cc every 20 minutes
evidence to suggest that evidence to suggest that consumption of a low consumption of a low carbohydrate drink during carbohydrate drink during prolonged and intermittent prolonged and intermittent exercise will improve exercise will improve performance (No one type is performance (No one type is superior to the other)superior to the other)
Sport drink comparisonSport drink comparison
RecommendationsRecommendations
If exercising less than 50 minute, benefits If exercising less than 50 minute, benefits of drinking questionableof drinking questionable
Heat injury may be more related to Heat injury may be more related to intensity of exerciseintensity of exercise
Recommendations of fluid intake more for Recommendations of fluid intake more for those athletes participating longer than 1 those athletes participating longer than 1 hourhour
Supplemental salt intake if greater than 4 Supplemental salt intake if greater than 4 hours activityhours activity
RecommendationsRecommendations
If activity less than 90 minutes, use If activity less than 90 minutes, use waterwater
But 6-8% CHO has been shown to But 6-8% CHO has been shown to sustain better power output after 60 sustain better power output after 60 minutes, so it may improve minutes, so it may improve performance particularly if no other performance particularly if no other nourishmentnourishment
Plus sports drinks may taste betterPlus sports drinks may taste better
Running InjuriesRunning InjuriesConclusionConclusion
Proper diagnosis of Proper diagnosis of injuryinjury
Understand goalsUnderstand goals
Treat underlying Treat underlying causecause
Treat kinetic chainTreat kinetic chain
Be sport specificBe sport specific
Make sense, be Make sense, be functionalfunctional
“If I knew that I was going to live this long, I would have taken better care of myself”-Mickey Mantle