treatment of the injured runner: evidence for clinical ......5.how to perform a gait evaluation ......
TRANSCRIPT
Treatment of the injured runner:
Evidence for clinical applications
Richard Willy, PhD, PT, OCSAssistant Professor of
Physical TherapyEast Carolina University
Greenville, NC [email protected]
Twitter: @rwilly2003
The presenter has no financial relationships or product endorsements to disclose
Outline
1. Epidemiology of running injuries
2. Causes of running injuries: perceived vs. actual
3. Envelope of function
4. Guidelines for treating runners5. How to perform a gait evaluation
6. Classifying running mechanics pertinent to injury
7. Address running mechanics identified as part of etiology
8. Role of shoes9. Therapeutic exercise: economy and for rehabilitation
The new running boomOnly 62% of Americans meet CDC
guidelines www.CDC.gov
Of these, 22% use running to meet levels www.CDC.gov
Upwards of 16 million Americans run at least 3x/week National Sporting Goods Association, 2009
Nearly a 300% increase since 1990 runningusa.org
1990: Female runners 25%
2013: Female runners 57%irunfar.com
Runningusa.org
19.4%-79.3% incidence of running injuries van Gent 2007
Novice runners: inc. >30BMI Nielsen 2014
If obese and novice, highest risk if initiate running with > 3km in the 1st week! Nielsen 2014
Shutterstock.com
Epidemiology of running injuries
Where do runners get injured? Steinacker, 2001 Taunton 2003
Foot14%
Thigh3.4%
Knee50%
Lower leg26.7%
Hip/pelvis9.7%
Ankle11.1%
Patellofemoral pain48.8% of knee injuries
Female: 62% Male: 38%
Often begins in adolescence, continuing into adulthood => PFOA?
Rathleff, 2013, Crossley 2011
Where do runners get injured? Taunton 2002, Callahan 2000, Matheson 1987, Cameron 2013, Lopes 2012
Tibial stress fractures(Tibial stress syndrome)
2.2-7.8%Female: 73.6%
Male: 26.4%6 weeks-9mo loss of running
Bennell and Brukner, 2005
Iliotibial band syndrome1.9-12%
Female: 62% Male: 38%
Leading cause of lateral knee pain
Taunton 2002
Achilles tendinopathy9.1-10.9%Female: 42%
Male: 58%Up to 45% fail treatment
Sayana 2007
PT and runners: the credibility gap
Get to know running
Understand typical training volume
Training errors may or may not be major cause of injuries!!!
Knowledgeable of shoes
Rely on shoe stores for shoe prescription
“Maybe running isn’t for you”
What do runners perceive as causes of running injuries?
Saragiotto 2015
Most frequently cited:
• Not stretching
• Excessive training
• Wearing the wrong running shoes for foot type• Inadequate/unbalanced diet
• Foot type changes
• “not respecting (my) body’s limits”
• Not warming up
RunningInjury
Structure
Mechanics
Physiology, Genetics
Central, psychosocial
Tissue qualities
Training loads
Tissue tolerance,
Ability to adaptBiomechanical
loading
Activity hx, Aerobic fitness Chen 2013, Warden 2014
Bone structure mass/density Beck 2014, Warden 2006
Calf strength, girthClansey 2012, Shindle 2012, Popp 2009
Health, Nutrition, Sleep Tenforde 2013, Lappe 2008
Psychosocial Moran 2013, Stephan 2009
Previous history Tenforde 2013
Load,
Loading cycles Warden 2014,
Taylor and Kuiper 2001
Impact rates Milner 2007, Zadpoor & Nikooyan 2011
Neuromuscular fatigue Milgrom 2007, Fyhrie 1998
Training errors Moran 2013
How to evaluate runnersI. History
A. Injury history: past and present
B. Volume, training breakdown, surfaces
C. Sleep habits, life stressors, emotional responses
D. Diagnostic testing/imaging
E. Stress Fx’s: Bloodwork (Vit. D, Ca++, Thyroid )
F. Type of shoes worn, orthoses
II. Musculoskeletal Screen: preliminary diagnosis
III. Lower quarter assessment
IV. Running assessment
V. Musculoskeletal evaluation
Do non-running factors matter?Sleep-Reduced incidence in stress fractures reduced with enforced
sleep (≥6 hrs) and reducing cumulative marching Finestone and Milgrom 2008
-Adolescent athletes: sleep <8 hours were 1.7x (95% CI: 1.0-3.0)
more likely to sustain injury Milewski 2014
Psychological stressors-Relationship between high perceived stress, unplanned
training volume and stress fracture incidence Moran 2013
-Perceived susceptibility to running injury and overall health threats predictor of prevalence of running injury (r2=0.24, p<0.01) Stephan 2009
Injuries during race preparationIn 12-16 weeks prior to a targeted
race:• Injury: #1 reason nonstarters
(42%) Clough 1987
• 16.3-33% will sustain injury van Poppel 2015, Buist 2008, Mallisoux2014
Novice runners 2.5X more likely to become injured than experienced Videbaek 2015
“…not possible to identify which training errors were related to running related injuries.” Nielsen 2012
Post-Rehab Load CapacityUninjured Load Capacity
Envelope of functionDye 2005
Figures courtesy of Tom Goom, BSc (Hons), MCS www.running-physio.com
Acute: Chronic workload (Gabbett, 2016)Hard training is protective!
Consistent, hard training is protective in runners Rauh 2015, Chen 2013, Warden 2014, etc.
Gabbett 20160.8–1.3
Training time (mins) x sRPE (session RPE rating) = Workload unit (arbitrary unit)
Cumulative loads
Peak loads Rate of loading
Willy and Meira, IJSPT, 2016
Will the real load parameter step forward?Nielsen et al., 2012, Edwards 2012, Miller 2014
Plantar fasciopathyAchilles tendinopathy
Gastrocnemius injuries
Patellofemoral painTibial stress injuries
Degenerative knee issues (OA)
Peak loads
Cumulative loads
Susc
eptib
le to
in
crea
sed
spee
d w
ork
Susceptible to increased running volume
Pathoanatomy or pathomechanics?
Distinctly different mechanics for Iliotibial band
syndrome
Treadmill vs. overground mechanics
Kinematics Fellin et al., 2008, Riley 2007, Willy 2016
Slightly shorter strideTend to land with a flatter foot (less dorsiflexed)Otherwise, very little difference Fellin et al., 2008
Performing 2-D video analysisMinimize perspective errors
Film at the same level as your joint of interest!
Performing 2-D video analysisMinimize perspective errors, cont’d
Key Views
Sagittal view: Whole body1. Trunk position? 2. Hip flexion, extension at toe off?3. Knee angle at footstrike?4. How much knee motion occurs?5. Overstriding? Angle of lower leg?
Sagittal view: Foot1. What is their strike pattern?2. Is there early heel off?
Key Views: cont’d
Rear view: Whole body1. Trunk position? 2. Pelvic drop?3. Hip adduction/medial collapse?4. Hip internal rotation?5. Knee varus thrust?6. Excessive toe out/toe in?7. Is there crossover gait pattern?
Key Views: cont’d
Rear view: Foot and ankle1. Wear does foot hit the ground?2. Is there a pattern of supination to
pronation to re-supination?3. Toe in/toe out?
Front view: Whole 1. How much medial collapse?2. Where is the patella pointing?3. Toe in/toe out?
Common running deviations
Medial Collapse Mechanics
Overstridingmechanics Crossover
mechanics
Injuries associated with medial collapseMostCommonRunningInjuries
%RunningInjuries Female/Male
PatellofemoralPain 22% 62%Iliotibial BandSyndrome 11% 62%
PlantarFasciopathy 10% 46%TibialStressInjuries 7% 57%AchillesTendinopathy 10% 42%
PatellarTendinopathy 10% 43%
Taunton,2002
Medial collapse mechanicsWhat motions are excessive?
What has stress/strain?
a) Patellofemoral jointb) IT Bandc) Tibia and Femurd) Trochanteric bursae) Piriformisf) Medial collateral ligamentg) Femoral acetabular impingementh) Plantar fascia, medial foot
structuresi) Medial kneej) Gluteal tendinopathy
Proximal mechanism in females with PFPContralateral Pelvic Drop
Hip Adduction
Hip Internal Rotation
Knee abduction
Demonstrated in cross-sectional and prospective studies
(Willy et al, 2012, Willson et al., 2007, Souza et al, 2009, Dierks et al, 2008, Noehren et al. 2013)
Axial view of PFJ
Lat Med
Lateral tracking of the patella
Iliotibial Band Syndrome
ITB: Lateral hip and knee stabilizer(Terry 1994, Zenz 2002)
Contralateral pelvic drop and Hip adduction (Noehren 2007, Ferber 2010)
Impingement primarily at the lateral femoral condyle
Primal Illustrations
Medial collapse: Stress fractures Pohl 2008
Tension
Compression
Medial Collapse: Piriformis and g. trochanteric bursitis, gluteal tendinopathy
Kinematics of FAI and Anterior Labral Tear
• Poor control of hip frontal and transverse plane motions during functional or sport activities Austin et al., 2008
• Control of HADD and HIR resulted in >50% reduction in FAI-related pain Austin et al., 2008
Austin et al., 2008
In healthy runners, no correlation with mechanics (Westcott and Willy, 2010)
In PFP, peak strength explains only 3-12% variance in running, jumping, squatting, step descent (Dierks et al., 2007, Willson and Davis, 2008, Souza and Powers, 2009)
Hip strength not predictive of PFP prospectively (Witvrouw et al., 2010, Rathleff 2014)
Hip strengthening does not alter abnormal hip mechanics (Snyder, 2008, Willy and Davis., 2011, Earl, 2011)
“Medial collapse:” What’s the cause?
Souza et al., 2009
Femoral AnteversionOnly with more severe
Souza et al., 2009
Prospective analysis of hip strengthLink not as clear!
Increased hip external rotation strength in PFP Boling 2009
Hip abductor weakness did not predict onset of PFP Boling 2009
Hip strength not predictive in “start to run” Thijs 2011
Hip strength not predictive of medial collapse mechanics Willson 2010, 2011
Prospective PFPNo difference in hip
strength
Hip strength not predictive of medial collapse mechanics
Cross Sectional PFPPFP demonstrate hip
strength deficits
Females with PFP demonstrate medial collapse mechanics
Hip strength deficits a result of PFP!!
Rathleff 2014
Which factors or combination of factors best predict greater hip adduction excursion during running?
MeaningfulpredictorsGMedonsettimeGMedduration
NotmeaningfulpredictorsPelviswidth/femorallengthHipabductionstrength/BWHipERstrength/BWHipExtstrength/BWGMed averageactivationGMax onsettimeGMax durationGMax averageactivation
DelayedandprolongedGMEDactivationpredictincreasedhipadductionexcursion
• P <0.001• R2 =0.45,Adj R2 =0.43• SEE=2.0degrees
Hip adduction prediction: uninjured femalesWillson et al 2009
Medial collapse: SummaryMedial collapse mechanics:
excessive hip adduction, IR, contralateral pelvic drop
Primary pathomechanic in females
Peak strength and alignment play very small role
Motor control of gluteal musculature driving factor
Endurance of gluteal musculature likely important
The effect of a hip strengthening program on mechanics during running and during a single leg squat Willy RW, Davis IS. J Orthop Sports Phys Ther. 2011 Sep;41(9):625-32.
0
2
4
6
8
10
12
14
Hip Abd Hip ER Hip ABD Hip ER
Hip
Tor
que(
%B
W*m
)
Hip Strength PRE POST
Trainers
*
*
Controls
Subjects: 20 Uninjured female “Collapsers”6-week intensive hip strengthening programLast 4 weeks: functional strength training
Willy and Davis, 2011
Results: Running Kinematics
Trainer HADD Trainer HIR Trainer CPD
PRE POST
-5
0
5
10
15
20
25
1 51% Stance
Deg
rees
(+) HADD
-12
-7
-2
3
8
13
18
1 51
% Stance
Deg
rees
(+) HIR
-15
-10
-5
0
5
10
15
1 51Deg
rees % Stance
(-) CPD
Willy and Davis, 2011
Pre-strengthening Post-strengthening
Wouters 2012, Snyder 2010, Bennell 2010
Why is strengthening insufficient to alter abnormal movement patterns?
Strengthening activates different areas of the motor cortex than skill training Jensen 2005
Skill training results in cortical re-organization, strengthening does not Remple 2001
Gait retraining for medial collapseReal time or mirror feedback
Noehren 2011, Willy 2012 & 2013
PRE Training 3 Months
Real time feedback Noehren 2011
Mirror feedback Willy 2012 & 2013
8-sessionsCued: reduction in medial collapse
Age (yrs) km/wk Duration of PFPS (yrs)22.1 ±1.5 23.7 ±11.3 4.3 yrs ±2.5
Results: Demographics and subjective data
Willy et al. 2012
Step 1: train the movement in walking
http://www.yawcam.com/
Software to stream webcam
Markers placed on outside of knees
Cue: “Push marker toward
walls”
Cue: “Push marker toward
walls”
Markers placed on outside of knees
Step 2: Train the movement in runningMedial collapse
BaselineWith video feedback
Cue: “Keep the markers level”
PostBaseline