Student will be able to describe the step by step process of evaluating injuries.
Evaluating Running Injuries in Clinic
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Transcript of Evaluating Running Injuries in Clinic
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Evaluating Running Injuries
in ClinicJim Chesnutt, M.D.
OHSU Sports Medicine ProgramOHSU Orthopaedics and Rehabilitation
and Family Medicine
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Common Running Injuries
• Look at biomechanics of running• Consider factors leading to
overuse injury• Identify common running injuries• Learn treatment and prevention
strategies
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Biomechanics of Running
• 1000 steps per mile• load is 2-3x body weight per stride• running shoes absorb shock but need new
shoes each 300-500 miles• shoes: cushion, support, traction• biomechanical abnormalities translate
forces up and down kinetic chain – Pelvis-hip-knee-ankle-foot
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Biomechanics of RunningThe Two Phases of GaitI. 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
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Mechanisms of Injury1. repetitive motion/ stress2. microtrauma3. stress or trauma >> adaptation or repair4. chronic or progressive pain and dysfxn or
mechanical failure (macrotrauma)5. phases of healing : I. inflammatory( 1-5 days)
II. regeneration( 3- 42 days)
III. remodeling( 14+ days)
Common Overuse Syndromes
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Common Overuse Syndromes
Stages1 : pain after activity only2 : pain during activity but not
affecting performance
3 : pain during activity causing restricted performance
4 : chronic pain, even at rest
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Common Overuse Syndromes
FactorsA. Intrinsic
1. Anatomical malalignment or defect
- e.g. flat foot, osteoporosis 2. Biomechanical dysfxn
- e.g. tibial torsion, over-pronation,inflexibility, muscle imbalance
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Common Overuse Syndromes
Factors B. Extrinsic1. 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
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Overuse Injuries: 5 Step Treatment (O’Connor FG et al, Phys and Sports Med 1992 ;21(7):128-142.)
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
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Running InjuriesRisks:
1) >40 miles/ wk2) previous injury3) >10% increase mileage per wk 4) foot, knee, and hip malalignment (hyper-pronation, weak hip flexor)
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Common Running Injuries
Most common:1) Patellofemoral Pain Syndrome 2) Medial Tibial Stress Syndrome
(“shin splints”)3) Iliotibial Band Friction Syndrome4) Plantar Fasciitis5) Achilles’ Tendinitis
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Common Running Injuries
6. Stress Fracture of Tibia7. Stress Fracture of Femur8. Exertional Compartment
Syndrome9. Female Athlete Triad10. Iron Deficiency
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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”
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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)
Patellofemoral Pain Syndrome
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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
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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)
Patellofemoral Pain Syndrome
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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
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“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
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Medial Tibial Stress SyndromeFactors
•runner, hard surface, poor cushion
•poor conditioning, sudden increased intensity and duration ( > 10% per week)
•excessive and rapid pronation, tight Achilles
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Medial Tibial Stress SyndromeTreatment
• better shoes– medial
stabilizer – cushioning
• not surgery
• relative rest(5-7d)
• ice massage• NSAIDs• Achilles stretch
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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
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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 50-60%– deep posterior 20-30%– all others 20%
• factors: non-traumatic, unknown• Rx: fasciotomy or limit activity
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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
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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
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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
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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
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Tibial Stress FractureFactors• 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 )
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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**
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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
Tibial Stress Fracture
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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
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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
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Female Athlete Triad
• Low energy balance/ Eating disorder– Overtraining– Undereating of calories
• Amenorhea– Fewer that 4 menstrual periods/ yr
• Osteoporosis
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Low Iron: Runners Anemia• Runners consume more iron that general
public• Low iron effects performance• Screen females/?men with ferritin
– Level above 30-60 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
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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
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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%
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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
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Stress Fractures
• Healing- average 3-6 weeks2 wks: metatarsal and fibula6-8 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)
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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
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Plantar Fasciitis
Factors• excess pronation or high, rigid arch• women > men• overweight and/or overtraining• poor arch support or cushion• tight heel cords
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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)
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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
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Factors
1. poor body mechanics- poor flexibility or alignment
2. training errors3. environmental factors4. athletic shoes
Achilles Tendinitis
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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
Achilles Tendinitis
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Running Shoe Prescription
• Evaluate shoe wear pattern and foot type
– Rigid foot– Normal foot– Floppy Foot
• Shoe type
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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
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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.
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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. 1997.
• Niemuth P et al. Hip Muscle Weakness and Overuse Injuries in Recreational Runners. Clin J Sports Med. Vol 15 (1), Jan 2005.