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Carey Rothschild, PT, DPT, OCS, SCS, CSCS University of Central Florida Program in Physical Therapy FPTA Annual Conference Sept. 15, 2012

Participation numbers (2011): National Sporting Goods Association

Run/Jog 6+days/year= 38.675 million

Run/Jog 100+ days/year = 9.17 million

Up 9% from 2010 to 2011

Sporting Goods Manufacturers Association

Run/Jog ≥ once = 50 million

Run/Jog 100+ days/year = 19 million

Record levels of participation

Nearly 518,000 people in the US completed a marathon in 2011

Shoes and apparel sales increase

Running apps add to the runner’s experience

Charity running

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Some due to acute trauma

Most primarily due to overloading of musculoskeletal structures

Microtrauma over a long period of time

Usually the result of a change in training

Pain during or immediately after running Pain or symptoms within the approximated

time span of beginning a running program Injury felt to be related to running Injury significant enough to cause a

restriction of running for at least a week

Taunton JE et al 2002; Buist I et al 2010

Incidence:

Uninjured runners followed over a time period

New injury analysis

Prevalence:

Retrospective look back at a group of runners

Was there and injury present at some point

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Prevalence rate: 54.8% Incidence rates: 19.4-79.3% Majority of injuries = LOWER EXTREMITY

Knee

Lower leg (shin, Achilles, calf, heel)

Foot (& toes)

Upper leg (Hams, thigh, quad)

Van Middelkoop M et al 2008, Van Gent RN et al, 2007

Medial tibial stress syndrome Achilles tendinopathy Plantar fasciitis ITB friction syndrome Stress fractures (metatarsals, tibia) Anterior knee pain: PFPS, patellar tendinopathy Meniscal injuries Spinal injuries

Lopes AD et al 2012

Intrinsic Anatomic variables

▪ Demographics: Gender, weight, height, personality type

▪ Biomechanical alignment and structure

▪ Flexibility & strength

Other variables innate to the individual ▪ General health, lifestyle &

behavioral factors

Extrinsic Training parameters

▪ Mileage, pace, intensity, frequency, duration

Running surfaces

Running shoes/orthotics

Running form

Wen DY, 2007

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History of previous injury!

Why?

Incomplete healing

Inadequate rehabilitation

Underlying structural or biomechanical factor

↓ functional capacity of repaired or scar tissue

Powell KE et al 1986

Age

Gender

Height/weight/BMI

Personality type

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Alignment & Structure

Femoral anteversion

Increased Q-angle

Tibial varum

Genu varum/valgum

Pes planus/pes cavus

Foot mobility (pronation/supination)

Leg-length discrepancy

Van Gent RN et al 2007, Taunton JE et al 2002; Wen DY 2007

Hip muscle imbalance associated with LE overuse injury in recreational runners

Runners with LE injuries:

Weak Hip ABD & Flex

Runners with PFPS:

Weak hip ABD & ER

Runners with ITB syndrome:

Weak hip ABD

Niemuth PE et al 2005; Finoff JT et al 2011

“Too much, too soon, too fast” Volume/Mileage: significant risk for RRI Intensity: Interval training + association with

RRI but not significant when adjusted to total training volume

Frequency: cumulative distance better indicator than lack of rest between runs

Nielsen RO et al 2012; Buist I et al 2010

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Generally, RRI may be associated with…

Increased running speed

Number of daily & weekly runs

Number of days run per week

No association found between running surface and injury incidence

Considerations: cambered surfaces and hills

van Gent RN et al 2007

No significant association between greater number of shoes and injury incidence

Selecting shoes based on plantar foot shape had little influence on injury risk

Van Gent RN et al 2007, Knapik JJ et al 2010

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Footstrike pattern and RRI

52 cross country runners

Habitual rearfoot strike (RFS) have significantly higher rates of repetitive stress injury than those who mostly forefoot strike (FFS)

Daoud AI at al 2012

Lots of running related injuries!

Greater incidence most associated with…

History of previous running injury

Higher weekly mileage/volume

Less experience

Rearfoot striking

History Musculoskeletal Exam Running Gait Evaluation

Meninger AK and Koh JL 2012; Magrum E and Wilder RP 2010

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Medical History Musculoskeletal Exam:

Biomechanical Assessment

Site-specific examination

Functional examination

Shoe Assessment Running Gait Assessment

Standard medical history Conditions, surgeries, medications, dietary habits

Pre-injury & current running history Pain complaints/Mechanism of injury

Location, duration, onset, course, quality, intensity

Exacerbating/ameliorating factors

Training habits

Previous treatments

Signs of overtraining

Female runners – “The Female Triad”

Clinical Presentation Common Diagnoses

Acute onset? Fracture, tendon rupture

History of injury, surgery, or pain?

Predisposed to scarring, stiffness, pain

Pain worse with exertion? Compartment syndrome

Pain improved with warm-up & stretching?

Muscle strain, MTSS

Pain improved with warm-up but worsens after the run?

Tendinopathy

Electrical, shooting pain, weakness, or numbness?

Nerve injury

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Plastaras CT et al 2005

Standing

Posture

AROM testing

Strength & balance tests

Provocation tests

Sitting

Inspection/palpation

PROM foot and ankle

Knee exam

Supine

Inspection & palpation

Hip, knee exam

Core stability

Sidelying

Hip ROM/strength

Prone

Hip ROM/strength

STJ neutral

Standing observation in 3 planes

Appropriate clothing, no shoes!

Spinal, pelvic, and LE alignment

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Check Pelvis & Hip Levels Palpate Iliac crest, ASIS’s/PSIS’s, GT

Assess pelvic tilt, ER/IR

Rule out LDD & SIJ Dysfunction Check Knee Alignment Q‐Angle, Patellar position

Genu varum/valgum/hyperextension Check Lower leg alignment Tibial Varum/Rotation

Foot/ankle posture

Look for:

Calcaneal Varus or Valgus

Hallux Valgus

Pes Planus vs. Pes Cavus

Angle of Toe Out

Callous & Blister Pattern

“Miserable malalignment syndrome"

Check in STJ Neutral

Gross LE: Double leg squat Ankle: Heel raise, inversion/eversion Foot: 1st MTP ext Spinal ROM

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1. SLS: EYES OPEN & EYES CLOSED

2. SINGLE LEG SQUATS

3. SINGLE LEG STRAIGHT LEG DEAD LIFT

4. SPLIT SQUAT

Done with bare feet! Look for:

Navicular drop

Intrinsic over activation

Level hips

Symmetry R vs. L

Eyes open and eyes closed Add LE reaching Add step-down

Plastaras CT et al 2005

Don’t Cue Them…………..at first! Observe: Squat depth

Hip & knee angle

Foot position

Angle of trunk lean Have them perform multiple reps Does their form get better?

Does their form get worse?

Is there pain?

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Can use dowel rod to cue posture Observe:

Squat depth

Hip & knee angle

Foot position

Angle of trunk lean

Balance

Observe:

Symmetry in available motion?

Balance

▪ Ankle control

▪ Hip control

Have them perform multiple reps!

Does their form get better?

Does their form get worse?

PAIN?

Strength testing: hip flexors, quads, hams, ankle

Neuro testing: slump test, seated SLR, reflexes, sensation

Foot and ankle exam: plantar skin, ROM

Knee exam: Patellar tracking

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Leg length Hip exam: ROM, FABER & scour test Knee exam: femoral & tibial torsion; Q-angle,

patellar mobility & tracking Flexibility: Thomas test, hamstrings, hip

adduction Core stability: bridge

Flexibility: Ober’s test

Strength: Hip ABD/ADD

Very important to check in runners!

Observation: soles of feet, calluses Flexibility: Quads Strength: Glut Max, Medial/lateral

hamstrings, Hip ER/IR STJN: forefoot/rearfoot relationship, lower

leg to rearfoot; 1st ray mobility Spine/SI: palpation and spring testing

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Inspection: swelling, ecchymosis, discoloration

Palpation: bone, soft tissues, tenderness, pain

ROM Neuro testing Special tests Related areas

Age/mileage of the shoe

Type of shoe

Lacing technique

Wear patterns: asymmetry

Overpronator Normal Pronater Underpronater

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Considerations:

Treadmill

▪ Constant speed

▪ Multiple strides

Overground

▪ More ecological

▪ Experience & comfort

Video camera

▪ Observation with human eye alone is insufficient

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Spatiotemporal

Step width

Step rate/length

Postural analysis

Frontal & sagittal planes

Midstance

Joint center alignment

Lateral pelvic tilt

Lateral distance from foot to body’s COM

Knee separation

Rearfoot/shoe alignment

Initial contact

Foot-ground angle

Horizontal distance from heel to body’s COM

Knee flexion angle

Midstance

Max knee flexion angle

Vertical displacement of COM

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Modalities Manual Therapy Massage Stretching Strengthening Orthotics Gait Retraining

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Protection: crutches, orthoses, braces, compression sleeves

Rest: cessation of running until ADL’s are painfree for 1-2 weeks

Ice: cryotherapy especially during acute phase

Compression: when swelling present; compression stockings 15-20mmHg graded pressure

Elevation: >15cm above heart Nicola & El Shami 2012

Analgesia vs. anti-inflammatory? NSAIDs (aspirin, ibuprofen, naproxen)

Recommended for swelling and pain

▪ Soft-tissue impingements, inflammatory arthropathies, tenosynovitis

Generally not recommended with stress fractures or chronic tendinopathy

Acetaminophen (Tylenol)

Recommended for pain relief

Paoloni JA et al 2010

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Uses: Pain relief after injury

Enhance initial stages of tendon & muscle regeneration

Evidence: In vitro studies Promote migration, proliferation, and collagen

synthesis by tendon cells, which are fundamental to the tendon-healing process

Limited high quality research suggesting US is effective for MS conditions of lower limb

Tsai WC et al 2011; Shanks P et al 2010

Uses:

Pain relief for musculoskeletal pain

Evidence:

Interferential current/TENS: potentially effective in reducing MS pain as part of a multi-modal treatment plan

Fuentes JP et al 2012; Hurley & Beane 2008

Joint mobilization

Soft tissue mobilization

Specific techniques by diagnosis

Massage

Conflicting evidence

Self-massage techniques

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Uses: Relieve secondary local mm spasm Hasten recovery

Techniques: Cross friction at early sign of reinjury in chronic conditions Proactive “sports” massage

Evidence: Conflicting evidence for effects on tendons and muscle

flexibility No evidence for muscle healing & recovery No physiological, injury or muscle soreness reduction

benefits were noted with regular massage therapy in novice runners

Nicola & El Shami, 2012

Foam rollers!! Uses:

Treating soft tissue restrictions or fibrous adhesions between layers of fascial tissue

Evidence:

Acute bout (2 min) of foam rolling on the quad significantly increased quad ROM

MacDonald G et al 2012

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Common flexibility issues:

ITB

Hamstring

Hip Flexors

Gastroc-soleus

Initial changes attributed to neural factors Further changes require change in sarcomere

number, taking several months

Nicola TL & El Shami AE, 2012

Passive: use of another person or apparatus to increase force applied during a static stretch

Active: Use of an antagonist muscle to generate a stretch without any passive assistance

Static: “elongation of a muscle to tolerance &

applying a force for a length of time”

PNF: Combines static stretching with isometric

contractions and relaxation to the limits of motion

Dynamic: Involves controlled movement through

active ROM

Nicola TL& El Shami AE, 2012

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Static stretching No evidence for reducing injury rates (Yeung SS et al 2011)

May have detrimental effects on performance when held >45s (Kay AD& Blazevich AJ, 2012)

Recommendation: 30 sec Dynamic stretching 10 min dynamic warm-up reported to improve

performance 4x30s dynamic stretches increased EMG activity (Behm

DG & Chaaouachi A, 2011)

Preactivity dynamic warm-up improved HS flexibility and quad strength (Aguilar AJ et al 2012)

PNF: Stretching with a partner or alone with a strap may increase ROM of the hamstrings (Maddigan ME et al 2012)

Hamstrings Seated active knee ext (4x30s) (Meroni R et al 2010)

▪ Maintenance of length vs. passive stretch at 4 wks

LE (Zourdos MC et al 2012)

Toe & heel walks

Hip Series

Hand Walks

Walking lunges

Walking groiners

Frankensteins

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We see injured runners because they are injured…

Do they stop running because of decreased performance?

No! They stop because they are injured!

However, we are still NOT SURE if stretching will lead to improved performance or reducing injury rates

Core Strengthening

Improved running performance and awareness of running posture & form (Sato K & Mokha M 2009)

Hip

ABD/ER strengthening led to alteration of joint loading & potential ↓ injury risk (Snyder KR et al 2009)

Isolated hip ABD/ER strengthening in PFPS shown to ↓ pain & improve function (Khayambashi K et al 2012)

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Lengthening of MTU as load is applied Characteristics vs. concentric exercise:

Less O2 consumption

Less energy expenditure

Greater force production

Effective treatment of tendinopathy as first-line intervention (Skjong CC et al 2012)

Effective in rehab of hamstring strain (Lorenz D &

Reiman M 2011)

Core strengthening

Planks, back extension on ball, hip raise on stability ball, prone “swimmer”

Hip Strengthening (Glut Med, Max, ER)

Side planks, SL squat, SL deadlift, Tband rotation, monster walks (Boren K et al 2011; Cambridge EDJ et al 2012)

Eccentric hamstrings: SL deadlift, Nordic hamstrings, split squats, plyometrics (Lorenz D &

Reiman M 2011)

Eccentric gastro-soleus complex: heel lowering

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Uses:

Antipronation:

▪ Increase medial longitudinal arch height

▪ Decrease tibial IR ad calcaneal eversion

Patellar position

▪ PFPS: medial and inferior

Antipronation:

Effective in controlling foot pronation when compared to foot orthoses and motion control footwear (Cheung RTH et al 2011)

PFPS:

HEP stretching program + McConnell taping decreased pain & increased function (Jessee AD et al

2012)

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Purpose of use:

Control motion

Accommodate

Types:

OTC

Customizable

Custom (rigid, semi-rigid, accommodative)

Beneficial to prevent a first occurrence of lower limb overuse conditions (Richter RR et al 2011)

No difference between custom & prefabricated Insufficient evidence to recommend for

treatment of lower limb overuse conditions (Richter RR et al 2011)

Custom may be slightly better than no inserts in treating MTSS (Yeung SS et al 2011)

Less effective when compared to taping & footwear in controlling rearfoot eversion (Cheung RTH et al 2011)

There is no break-in period for running shoes!

If they do NOT feel good immediately, they are not for you!

General recommendations: Lightest shoe Feels good Holds the patient up (in SLS the shoe

hold the foot upright without collapsing in to far)

No evidence for selection by foot type (Yeung SS et al 2011)

Nicola & El Shami 2012

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Can be used to REST the foot Can assist in keeping runner running May need to be more aggressive initially Better to UNDER correct than OVER correct Arch taping may be beneficial initially Consider the shoe it is going into Address running mechanics first!

What can we attempt to modify with retraining?

Step rate/cadence

Step length

Loading rate

Foot strike pattern

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45 runners modified step rate +5 and +10% of preferred via use of a metronome

Decreased peak HADD angle & peak HADD/IR moments during loading when step rate increased 5 and 10% over preferred

10 males modified step rate -15, -30 and +15, +30% of preferred

LE loading minimized at +15% of preferred step rate

Heiderscheict B et al 2011

Hobara H et al 2011

Shorter step length

Altered footstrike pattern & loading response

Increased knee angle at foot strike

Gait retraining can reduce LE impact loading using real-time visual feedback Verbal cues to “land softer”

Reduced LE impact may lead to reduced risk for stress fractures

Crowell HP & Davis IS 2011

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Significant improvements in hip mechanics & pain (↓ in HADD and contralateral pelvic drop) in 10 females with PFPS

Use of real-time visual faded feedback

Noehren B et al 2011

3 runners with PFPS underwent 8 sessions of gait retraining using real-time audio feedback

Landing pattern changed from a rearfoot to non-rearfoot strike

Vertical impact peaks and loading rates were reduced

Cheung RTH & Davis IS, 2011

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1. No pain with walking 2. Minimal to no swelling 3. Functional ROM 4. At least 70% strength compared to the

affected LE (post-surgical injuries)

www.sportsmedicine.osu.edu

Phase I: Plyometrics

Phase II: Walk to Run Progression

Phase III: Running Progression

Double leg to single-leg jumps/hops

Address form: Toe-heel landing

Triple flexion/ triple extension

Soft landing No pain! Tolerates 200-250 foot

contact before progression (1/3 mile of running)

www.sportsmedicine.osu.edu

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Basic: For runners who are returning from post-surgical injuries & rec runners running <20 miles per week

RUN WALK REPS DAYS

Phase A 1 min 1-5 min 2 2

Phase B 2 min 1-4 min 2 2

Phase C 3 min 1-3 min 2 2

Phase D 4 min 1-2 min 2 2

Phase E 5 min 1 min 2 2

www.sportsmedicine.osu.edu

Advanced: Athletes with non-surgical injuries, previously running 40-60 miles/week

Completes all phases without pain or symptoms

www.sportsmedicine.osu.edu

Gradual increase in mileage & return to normal running routine within 5-6 weeks

Cross-train on rest days, but at least 1 TOTAL rest day per week

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Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 TOTAL

Week 1 - 1 - 1 - 2 - 4

Week 2 - 2 - 3 - 3 - 8

Week 3 - 4 - 4 - 2 - 10

Week 4 4 - 2 2 - 4 - 12

Week 5 4 - 3 3 - 4 - 14

www.sportsmedicine.osu.edu

Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 TOTAL

Week 1 2 - 2 - 3 - 3 10

Week 2 - 4 - 4 - 3 3 14

Week 3 - 5 - 5 4 - 4 16

Week 4 5 - 6 5 - 6 - 22

Week 5 6 - 7 7 - 9 4 32

Week 6 - 7 10 4 - 12 7 40

www.sportsmedicine.osu.edu

Need to obtain a thorough history! Need to do a thorough exam! Biomechanical

Strength & flexibility

Movement patterns Relate all exam findings to gait assessment Select validated treatment options! Core & hip strengthening

Gait retraining