@DrChrisBarton semrc.blogs.Latrobe.edu.au
Managing the runner with knee OA
Dr Christian Barton PhD, Bphysio (Hon), MAPA, MCSP
Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, AustraliaClinical Director and Physiotherapist, Complete Sports Care, Melbourne, AustraliaAssociate Editor British Journal of Sports Medicine and Physical Therapy in Sport
@DrChrisBarton semrc.blogs.Latrobe.edu.au
A little about me
@DrChrisBarton
1. Loves running, and has run all her life
2. Left knee pain on and off past 2 years following a fall
3. Running is Ok, until > 5km
4. Lots of pain recently trying to train for ½ marathon
5. Intense pain for 3-4 days after 15km run recently
6. Recently tried changing strike pattern to forefoot strike – no help
@DrChrisBarton
1. Extruded medial meniscus, with horizontal tear periphery of the posterior horn and tiny vertical tear free edge posterior horn.
2. Focal tiny chondral cleft articular cartilage MFC.
3. Mild to moderate chondromalacia patellae.
4. Moderate joint effusion and synovitis.
5. Complex Baker's cyst, with likely rupture inferiorly.
@DrChrisBarton semrc.blogs.Latrobe.edu.au
“Physical activity and exercise therapy not only improve
symptoms and impairments of OA, but are also effective
in preventing at least 35 chronic conditions and treating at
least 26 chronic conditions, with one of the potential
working mechanisms being exercise-induced anti-
inflammatory effects.”
@DrChrisBarton semrc.blogs.Latrobe.edu.au
RISKS BENEFITS
@DrChrisBarton semrc.blogs.Latrobe.edu.au
RISKSBENEFITS
RUNNING?
1. Pain?2. OA progression?
@DrChrisBarton semrc.blogs.Latrobe.edu.au
OA present
6 studies reported no effect on cartilage
thickness, volume or defects
1 study reported a negative effect + 1 no
effect on GAG
2 studies reported a positive effect + 2 no effect on collagen.”
Risk of OA
1 study reported no effect on cartilage defects
1 study reported positive effects on
glycosaminoglycans (GAG)
@DrChrisBarton semrc.blogs.Latrobe.edu.au
25 studies
Competitive or recreational?“Specifically reported that the runners were professional, elite, or ex-elite athletes, or in any case in which runners represented their countries in international competitions.”
@DrChrisBarton semrc.blogs.Latrobe.edu.au
The right amount of load is good!
Andriacchi, T.P., et al., A framework for the in vivo pathomechanics of osteoarthritis at the knee. Ann Biomed Eng, 2004. 32(3): p. 447-57.
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
RUNNING? Prevent at least 35 chronic conditions (Booth 2012)
1. Pain?2. ??OA progression??
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Principle of ‘RISK’ management
R educe overall load
I mprove capacity to attenuate load
S hift the load
K eep adapting to the capacity and goals of the runner
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Load management
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Load management
2. Gradually adapt capacity to handle load
1. Reduce the load
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Loading may be biggest issue
Load management is vitally important
Why does it still hurt!?!
@DrChrisBarton
Pain
Maladaptive Behaviours
- Physical changes
- Non-physical changes
- Increased stress
- Decreased capacity
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Key considerations in knee
Proximal
- Pelvic drop
- Hip control
- Knee extension/flexion
Distal
- Foot strike pattern
- Over-striding
@DrChrisBarton semrc.blogs.Latrobe.edu.au
1. Lower step rate
2. Landing further from centre of mass (i.e. over-stride)
3. Greater centre of mass vertical excursion
4. Greater ankle dorsiflexion at foot strike
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Increase step rate
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Addressing over-stride with step rate
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Who• Mixed-sex cohort of runners with PFP • > 3 months and aged 18-45• Running a minimum of 10KM/week
What• 6 weeks increasing by 7.5% (metronome)• Faded feedback design• 1 structured session per week • Pain and lower limb kinematics measured
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Three categories:
- Kinematics (motion we can see and assess)
- Kinetics (forces which drive the motion) - INJURY
- Neuromuscular/EMG function (control of kinematics and kinetics)
Is the issue kinematics or neuromotor?
Biomechanics are not simple
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Life is a ‘bell curve’
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Running retraining?
1. Identifying any theoretical (abnormal) running mechanics which may be contributing to tissue overload
2. Establish if running mechanics can be altered
3. Facilitate the desired running mechanics changes and encouraging motor learning to ensure maintenance of any change
CHANGE THE PATH OF LEAST RESISTANCE
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Is Running Retraining evidence based?
“Our synthesis of published evidence related to clinical outcomes and biomechanical effects with expert opinion
indicates running retraining warrants consideration in the treatment of lower limb injuries in clinical practice”
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Methodolgy
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Evidence Biomechanics
Intervention
8 sessions (2 weeks)
Visual and verbal feedback to
reduce hip adduction
Outcome
Reduce pain and improve
function
Patellofemoral Pain – Limited Evidence (Noehren2011; Willy 2012)
@DrChrisBarton semrc.blogs.Latrobe.edu.au
In clinical practice?
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
@DrChrisBarton semrc.blogs.Latrobe.edu.au
“There were no significant adverse events that occurred in either group.”
“Subjects in the experimental group reported calf soreness during the retraining phase. However, this subsided by session six for all of the subjects in the group.”
“Two subjects in the experimental group (25%) reported ankle soreness associated with the new running gait at the one-month follow-up. Subjects described it as an ache that quickly subsided after they discontinued running.”
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Transition from rearfootto forefoot strike
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Highly researched ≠ gold standard
@DrChrisBarton semrc.blogs.Latrobe.edu.au
“1.2–1.6⁰ of internal femur rotation for every 5⁰ of anterior pelvis tilt”
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Manage ‘RISK’ in running
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Principle of ‘RISK’ management General strategies
R educe overall load- Reduce running- Address over-stride- Increase step rate
Manage ‘RISK’ in running
@DrChrisBartonModified from Thomeé (1997)
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Principle of ‘RISK’ management General strategies
R educe overall load- Reduce running- Address over-stride- Increase step rate
I mprove capacity to attenuate load- Graduated loading- Strength and Conditioning- Muscle activation cues
Manage ‘RISK’ in running
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Graduated loading
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Principle of ‘RISK’ management General strategies
R educe overall load- Reduce running- Address over-stride- Increase step rate
I mprove capacity to attenuate load- Graduated loading- Strength and Conditioning- Muscle activation cues
S hift the load
(Most retraining strategies)
- Reduce anterior pelvic tilt (gluteals and core)- Increase knee flexion (quads)- Transition to midfoot/forefoot strike (calf)
Does the individual possess capacity?
K eep adapting to the capacity and goals of the runner
Manage ‘RISK’ in running
@DrChrisBarton semrc.blogs.Latrobe.edu.au
Take Home
1. Running is good for you
2. Manage ‘RISK’ in the injured runner
3. Load management + getting/staying strong is key
4. Change sagittal plane running mechanics first
5. Consider barriers that prevent desired changes
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