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Running Injuries

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Title: Running Injuries


1
Running Injuries
  • Karl B. Fields, M.D.

Director of Sports Medicine Fellowship and Chief
of Family Practice Residency Moses Cone
Hospital Greensboro, N.C. 2007
2
Introduction / Running
  • Primary fitness activity of 10 - 20 of
    Americans
  • Popularized by Frank Shorter, Ken Cooper, Jim
    Fixx and road races
  • Competitors of all ages and after 10 years 56
    still run and 81 exercise regularly
  • Koplan, MSSE, 1995
  • Running is an efficient way to develop fitness
  • Recommendation strength A/ evidence level 1

3
Greatest Benefit of Running - Fitness Correlates
With Longevity?
  • Blair, et al Jama 1989 1995
  • Harvard Alumni Jama 1995
  • Finish athletes, Norwegian men, Swedish women
  • Men with or without CVD referred for ETT / men or
    women referred for exercise thallium. 2002
  • Fitness correlates with longevity
  • Rec A/ Level 1 evidence

4
Biomechanics of Running
  • Effect of external and internal forces on a
    biological system
  • Muscular force must overcome gravity and
    resistance
  • Muscles, bones, cartilage, ligaments and tendons
    must absorb impact

5
Gait and Foot Strike are Variables
6
Gait Cycle
  • Differs from walking - an airborne phase is
    present
  • Efficient Running - a straight line (runners show
    1 line in sand as opposed to walkers who leave
    two parallel lines.)
  • Over-striding may lead to bounding with too
    much vertical displacement

7
Primary Problem of Runners
  • Musculoskeletal injury
  • 40 to 60 of runners injured yearly
  • 25 or runners injured at any given time
  • Young and inexperienced runners have a
    preponderance of shin pain
  • Knee injuries common in all age groups
  • Male runners over 40 calf and achilles injury

8
EBM shows Influence of Orthopedic Factors
Variable
  • Leg length inequality
  • results variable for ITB, Pelvic, low back
    injuries
  • Excessive Q angle
  • more negative than positive studies in PFSS one
    positive study in stress fractures
  • Cavus feet
  • Study confirmed a RR of 6 for lower extremity
    injuries with highest arch height
  • Cowan, Arch Fam Med, 1993, level of evidence 2

9
Risk Factors for Recurrent Stress Fracture
  • 19 male/ 12 female athletes with avg of 3.7
    stress fractures vs. 15 controls /61 were
    runners
  • Stress fractures 70 in men tibia and fibula
    /50 in women were ankle or foot
  • High running mileage
  • Cavus foot 40 injured vs 13 controls
  • Leg length inequality/ forefoot varus
  • Korpelainen, et al. Am J Sp Med 2001, evidence
    level 2

10
Psychological Injury Factors - Documented in
Small Studies
  • Personality type - negative studies
  • Type A behavior
  • (Fields, JFP, 1989 Diekhoff J Sp Beh, 1984)
  • Obsessive-compulsive behavior/ Obligatory runners
  • (Yates, Psychosomatics, 1992)
  • Hostility
  • Rec level C/ Evidence level 2 to 3

11
Running Injury - Best Evidence Study Results
  • Previous Injury in preceding 12 mos (RR 1.51)
  • Mileage greater than 40 per week (RR 2.88)
  • Possibly daily running/ long runs
  • 115 runners in controlled training of 18 to 20
    months/ 85 injured/ training distance was risk
    factor
  • Boven, et al Int J Sp Med, 1989
  • Higher running mileage causes running injury
  • Rec B /evidence level 2

12
Common Running Injuries
  • Patello-femoral Stress Syndrome (PFSS)
  • Iliotibial Band Syndrome
  • Plantar Fasciitis
  • Tibial Stress Fracture/ MTSS
  • Achilles Tendonosis

13
Additional Running Injuries
  • Metatarsalgia
  • Strains of hamstrings, adductors, piriformis
  • Patellar, posterior tibialis, peroneal,
    ilio-psoas tendonosis
  • Tarsal tunnel, sural, peroneal neuropathies
  • Femoral, navicular, medial malleolar, proximal
    5th MT, sessamoid stress fxs

14
Goals for Running Injury
  • PFSS
  • ITB
  • Achilles Tendonosis
  • MTSS/ Tibial Stress Fx
  • High Risk Stress Fxs

15
PFSS Treatment
  • Quadriceps exercises
  • Icing
  • Patellar straps, McConnell taping, patellar
    sleeves with pads, antipronation pads, orthotics,
    use of NSAIDs orally or topically
  • Cochrane review notes better clinical results
    with standard treatments in studies but
    inconclusive evidence to rate effectiveness

16
Exercise Therapy for PFSS
  • 12 trials but only 1 high quality and 2 low
    quality were controlled
  • Significantly greater pain reduction in 2 of 3
    trials
  • level 2
  • Greater functional improvement in 1 of 3 trials
  • level 2
  • Strong Evidence that open and closed chain
    exercise are equivalent
  • Rec A/Level 1
  • Berger, et al. Cochrane Library 2004

17
Evidence for Addressing VMO Weakness and Cavus
Feet
  • Quadriceps weakness may be common factor in LDR
    with knee pain
  • Supination and rigidity may be more of a problem
    than pronation which implicates Cavus feet as an
    anatomical factor
  • Level of evidence 2
  • Mileage, stretching, impact, shoes may play
    lesser roles than thought
  • Etiologic Factors Associated with Anterior Knee
    Pain in Distance Runners, MSSE vol 32 no 11 Nov
    2000, Duffey et al

18
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19
Iliotibial Band Syndrome What Do We know?
  • Variable sharp pain at different paces
  • Pain aggravated by down hills and sloped
    surfaces, increased mileage (Messier, MSSE, 1995)
  • Precipitating factor often unclear
  • Non-impact activity does not cause pain - biking,
    swimming, stair-master
  • Impingement at or below 30 deg knee flexion on wt
    bearing (Orchard, Am J sp Med 1996)

20
Standard ITB Treatment
  • ITB stretches
  • Ice, NSAIDS, injection
  • Friction massage and PT modalities
  • Antipronation pads or orthotics
  • Variable paced workouts
  • Level of evidence is 3

21
Prospective Study of ITB
  • 24 consecutive distance runners diagnosed with
    ITB at an injury clinic
  • 14 males and 10 females
  • Average age 27
  • Control group of 30 Stanford runners -14 female
    and 16 male with mean age 20

22
Methods
  • Lateral leg lift in lying position against a
    dynamometer until failure
  • 2 test measures before true test
  • Results normalized for height and weight

23
Why Did ITB Improve?
  • The gluteus medius is a continuous abductor in
    stance phase with some assistance from the tensor
    fascia lata
  • At footstrike both muscles undergo eccentric
    contraction
  • Weakness of gluteus medius in particular allows
    increased thigh adduction which increases genu
    valgus and stresses the ITB

24
Results
  • Injured runners showed strength deficits versus
    uninjured leg and versus controls
  • (all p values lt.05)
  • Males showed 51 and females 35 increase in
    strength after 6 wks rehab
  • 22 of 24 pain free at 6 weeks 1 at 3 months
  • Evidence level 2/ Rec level B
  • Hip Abductor Weakness in Distance Runners with
    ITB, Fredericson, Cookingham, et al., Clin J of
    Sports Med July 2000

25
Dynamic Genu Valgus
26
Achilles Tendonosis Treatment
  • Heel cup, heel pads, ice massage, stretching
  • NSAIDS orally or topically
  • Oral prednisone
  • Training change
  • All have equivocal evidence
  • Steroid injection doesnt appear to help
  • Shrier, CJSM 1996

27
Heavy-load Eccentric Calf Muscle Training
  • 15 experimental/ 15 controls - all recreational
    athletes
  • Loaded eccentric contraction from a step
  • All 15 experimental of experimental group
    recovered in 12 weeks (and cancelled their
    surgery!) versus 0 of controls
  • Alfredson, et al. AM J Sp Med 1998
  • Perform eccentric calf strengthening to treat
    Achilles Tensonosis Rec B/ evidence level 2

28
Eccentric Strength Exercises for Achilles Injury
29
Eccentric Exercise Changes Tendon Structure
  • Eccentric exercise decreased tendon thickness and
    normalized tendon structure measured by
    ultrasound
  • 25 patients followed on average 3.8 years with 26
    tendon injuries
  • Ohberg, et al. Br J Sports Med 2004
  • Eccentric Training of the Gastrocnemius-Soleus
    Complex in Chronic Achilles Tendinopathy Results
    in Decreased Tendon Volume and Intratendinous
    Signal as Evaluated by MRI
  • Shelby et al., American Journal of Sports
    Medicine, vol. 32, no. 5, 2004

30
MTSS or Shin Splints 4 studies Qualify for
Cochrane
  • Andrish - heel pads, stretching, heels pads plus
    stretching, graduated running
  • Bensel - canvas vs standard leather boots
  • Bensel - urethane vs mesh vs grid insoles
  • Schwellnus - neoprene insoles
  • Results showed only that neoprene insoles cut
    injury risk, particularly MTSS

31
Evidence Summary for MTSS
  • Of 4 RCTs all included military recruits
  • Results affected by Confounding variables and
    limits to randomization
  • Quality scores ranges from 29 t0 47 out of 100
  • Lack of preseason training as a risk factor
  • Shock absorbing orthotic insoles may reduce risk
    in males
  • Rec B/ evidence level 2

32
Tibial Stress Fracture/ Exam
  • Direct tenderness
  • Pain on tuning fork
  • Positive hop test
  • Swelling

33
Tibial Stress Fracture Treatment
  • No running for a minimum of two weeks/ much
    longer for upper or mid tibia
  • Progressive increase in activity while using long
    air splint
  • Long air splints received a favorable review by
    Cochrane with return to training 42 days faster
    than standard therapy
  • Rec B/ level 2

34
High Risk Stress Fractures
  • Femoral neck
  • Medial malleolar
  • High or anterior tibia
  • Intraarticular - e.g. tibial plateau or patella
  • Sessamoids
  • 5th Metatarsal

35
Navicular Stress Fracture
  • N spot - proximal dorsal navicular
  • Return to sport slow - avg of 5.6 months
  • 11 of 45 healed with weight bearing Rx
  • 32 of 36 healed with non weight bearing Rx
  • 22 of 27 nonunions healed with surgery
  • 86 of 128 false negative plain films
  • 77 of 131 cases had successful return to sport
  • Stress Fractures, Bruckner and Bennell

36
Summary of Navicular Stress Fracture
  • Only 25 heal with weight bearing
  • NWB appears to be successful in gt 85
  • 85 non-unions heal with surgery
  • Return to sports remains problematic with only
    60 returning to previous level
  • Evidence level 2

37
Running Injury Treatment
  • Evidence supports treatment approaches in a
    limited number of running injuries
  • Opinion suggests control inflammation, modify
    training and gradually increase.
  • Rehabilitation focuses on eccentric strength with
    evidence for Achilles and hamstring.
  • Special protection long air splints and
    orthotics have some support.
  • Stretching before running does not appear
    protective against injury

38
Running Summary
  • Key exercise for aerobic fitness
  • All body types have had success
  • Ability to compete at all ages
  • High risk for musculoskeletal injury
  • Primary benefit for overall health and longevity

39
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