Running Injuries: The Latest and Greatest

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Running InjuriesThe Latest and Greatest

• CPT Matt Fandre
• USAFP 2007

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Agenda

• Running Shoes
• Myth of flat feet
• ITB
• RPPS
• Stretching
• Cross Training
• Stress Fractures
• Endurance Events
• Exercise Hyponatremia
• Conclusion

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Running Shoes

• Running shoes are best matched to running style
  (foot strike, loading rate, etc.)
• It is safe to empirically follow this guide
• Low arch/pronator Motion control shoes
• High arch Cushioned shoes
• Neutral Stability shoes

American Journal of Sport Medicine, AUG 2006,
Butler, et al.
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Flat Feet Myth

• High arched runners are more likely than flat
  feet runners to suffer overuse injuries

Foot morphologic characteristics and risk of
exercise related Injury, Arch Fam Med
19932(7)773 7, Cowan DN, Jones BH, Robinson
JR.
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ITB

• Common source of knee pain (lateral) in runners
• Evidence that this is more an overuse injury than
  a mechanical predisposition
• Pain worse running down hills or increasing
  stride length
• Treatment
• RICE, NSAIDs, Injection (consideration)
• Stretching of hip flexors and plantar flexors
• Strengthening needs to focus on gluteus medius
  muscles

ITB A common source of knee pain, AFP, APR 15,
2005, Razib Khaund and Sharon Flynn
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ITB Treatment
STRETCH
STRENGTHENING
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RPPS

• Five-year prospective, randomized trial
  investigated long-term effects of open kinetic
  chain and closed kinetic chain exercises in the
  treatment of RPPS.
• Only 20 of patients reported being pain-free at
  five years
• Open kinetic chain group had less pain on the
  visual analog scale at night, less swelling of
  the joint, and less pain descending stairs as
  compared with the closed kinetic chain group
• Open kinetic chain exercises do not need to be
  avoided and should augment traditional closed
  kinetic chain exercises

Open versus closed kinetic chain exercises in
patellofemoral pain a 5-year prospective
randomized study, Am J Sports Med, 2004,
Witvrouw E, Danneels L, Van Tiggelen D, Willems
TM, Cambier D.
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Open vs. Closed Chain

• OPEN CHAIN (Distal part not fixed)
• quadriceps exercises (i.e., maximum isometric
  quadriceps contraction in full extension)
• straight-leg raises
• leg adduction exercises in a side-lying position

• CLOSED CHAIN (Distal part fixed)
• seated leg presses-one-third knee bends on one
  leg or both
• stationary bicycling
• rowing machine exercises
• step-up and step-down exercises

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Stretching

• Pre-exercise stretching does not decrease lower
  extremity running injuries
• Stretching does reduce soreness after exercise
  (2)
• A summary of 23 articles
  on stretching revealed an
  improvement in speed,
  but not running economy

Randomized trial of pre-exercise stretching,
Medicine Science in Sports Exercise, FEB
2000, Pope, R.P., etal. Effects of stretching
before and after exercise, BMJ, 2002, Herbert Rd,
Gabriel M. Does stretching improve performance?,
Clinical Journal of Sport Medicine, Sep 2004,
Shrier, Ian.
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Rehab/Cross Training

• Study compared 2 mile times
• Water training
• Cycling
• Running
• No change in run times between the groups
• Cross training is effective in maintaining
  conditioning

Effect of water running and cycling on max O2
consumption and running time, Am J of Sports
Medicine, Vol 21, Issue 1, 1993, Eyestone, ED,
etal.
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Stress Fractures

• Occur in 13 to 37 of runners
• Most heal in 6 to 8 weeks if compliance with
  protected weight bearing is followed
• In 2/3 of symptomatic patients, radiographs are
  initially negative
• Only half develop positive radiograph findings
• Most common sign in early stress fracture is a
  region of focal periosteal bone formation
• Bone scintigraphy is highly sensitive but lacks
  specificity in small joints such as the ankle and
  foot
• MRI is also useful in the diagnosis of stress
  reaction and stress fracture
• High degree of sensitivity and a higher degree of
  specificity relative to bone scintigraphy

Imaging of Stress Fractures in Runners, Clin
Sports Med 25 (2006) 781802, Joseph Wall and
John F. Feller.
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Stress Fracture Images
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Stress Fracture Images
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Stress Fractures

• Leg length inequality may be a risk factor
• Higher incidence of tibial, metatarsal, and
  femoral fractures in the longer leg
• Higher incidence of fibular stress fractures in
  the shorter leg
• Anterior tibial, medial malleolus, talus,
  navicular, fifth metatarsal, and sesamoids have a
  higher rate of nonunion
• Treatment of recalcitrant stress fractures with
  intramedullary nailing has enabled patients to
  return to sports at an average of four months.
  This is an option for the treatment of chronic
  tibial stress fractures

Overuse injuries tendinopathies, stress
fractures, compartment syndrome, and shin
splints, Clin Sports Med 23 (2004) 558, R.P.
Wilder, S. Sethi What's New in Sports Medicine,
The Journal of Bone and Joint Surgery (American).
200688457-468 L. Joseph Rubino, III, and Mark
D. Miller
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Endurance Events

• 2-8 of marathon runners seek medical care
• Four hours post marathon average CK rise of 540
• Risk of sudden death
• Running
• 1396,000 man-hours
• Marathon
• 1215,000 man hours

Medical problems of marathon runners, Am J oF EM,
2006, Sanchez, Leon, Brian Corwell, and David
Berkoff.
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Exercise Induced Hyponatremia

• Severe hyponatremia may occur during events
  lasting longer than one hour
• 3 mechanisms
• Loss of electrolytes without enough replacement
• Fluid overload (water)
• Inappropriate fluid retention (aldosterone/ADH)
• Risk factors
• BMI lt 20, female, temperature, longer race time,
  gt 3L of fluid during the race
• Treatment
• Alternate between water and sports drinks
• No more than 1liter of water/hour
• Treatment does not involve rapid infusion of IVF.

Medical problems of marathon runners, Am J oF EM,
2006, Sanchez, Leon, Brian Corwell, and David
Berkoff. ACSMs Certified News, JAN-MAR 2006,
Jacalyn McComb.
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Summary

• Wear good shoes namely, shoes that work for you
• Strengthen medial glutes for ITB
• Proper conditioning is more likely to reduce
  injuries than stretching
• Pay special attention to anterior tibial, medial
  malleolus, talus, navicular, fifth metatarsal and
  sesamoid stress fractures
• Dont overconsume water before/during endurance
  events
• If you treat these patients, be aware of
  hyponatremia
• Use the knowledge of the smart folks

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Resources Thanks

• Sports Medicine Fellows
• PT department
• Textbook of Running Injuries
• Clinical Journal of Sports Medicine
• American Journal of Sports Medicine
• Medicine Science in Sports Exercise
• Thank you to Dr. Kane, Dr. Brennan, and Dr.
  OConnor