Common Running Injuries: Common Running Injuries: Prevention & RehabilitationPrevention & Rehabilitation

Shana Margolis, MDShana Margolis, MDAttending Physician, Rehabilitation Institute of ChicagoAttending Physician, Rehabilitation Institute of ChicagoClinical Instructor, Northwestern Feinberg School of Clinical Instructor, Northwestern Feinberg School of

MedicineMedicine

Davalyn Partain, PT, DPTDavalyn Partain, PT, DPTPhysical Therapist, Department of Orthopaedic Physical Therapist, Department of Orthopaedic

Surgery, Northwestern Medical Faculty Foundation, Surgery, Northwestern Medical Faculty Foundation, Rehabilitation Institute of ChicagoRehabilitation Institute of Chicago

June 16, 2010June 16, 2010

AcknowledgementsAcknowledgementsChristopher Plastaras, MDChristopher Plastaras, MDJoseph Ihm, MDJoseph Ihm, MDPaul Lento, MDPaul Lento, MDJo Fasen, PT, MPT, OCS, CSCS, Cert. MDTJo Fasen, PT, MPT, OCS, CSCS, Cert. MDT

What is Physiatry?What is Physiatry?Also called physiatrists Also called physiatrists

(fizz ee AT’ trists) (fizz ee AT’ trists)

Physical Medicine & Physical Medicine & RehabilitationRehabilitation

““Physicians of Function”Physicians of Function”

4 year residency program4 year residency program

Evaluation and Treatment of Evaluation and Treatment of all disabilitiesall disabilities

Musculoskeletal and Sports Musculoskeletal and Sports medicine is one aspectmedicine is one aspect

Musculoskeletal Healthcare Musculoskeletal Healthcare ProviProvidersders

Orthopedic Surgeons Orthopedic Surgeons and Podiatristsand Podiatrists– Operate on bones, Operate on bones,

tendons, ligamentstendons, ligaments

Types of Physicians:Types of Physicians:Physical Medicine & Physical Medicine & Rehabilitation Rehabilitation (Physiatrists)(Physiatrists)– Non-operative Non-operative

care of care of musculoskeletal musculoskeletal problemsproblems

Physical Physical Therapists & Therapists & Occupational Occupational TherapistsTherapists– Specialize in Specialize in

designing designing exercises for exercises for muscle, bone, muscle, bone, nerve problemsnerve problems

Athletic Trainers, Athletic Trainers, Physical Therapists Physical Therapists Assistants & AidsAssistants & Aids– Work closely with Work closely with

physical therapists to physical therapists to instruct on proper instruct on proper exercise techniqueexercise technique

Running Coaches, Running Coaches, Personal Trainers, Personal Trainers, Pilates/Yoga Pilates/Yoga InstructorsInstructors– Advance Advance

physical fitness physical fitness in people in people without without pathology or pathology or painpain

PhysiciansPhysicians– DiagnoseDiagnose– Order testsOrder tests– Prescribe MedsPrescribe Meds– Prescribe therapyPrescribe therapy– Prescribe Prescribe

interventions interventions (injections/surgery)(injections/surgery)

ChiropractorsChiropractors– Specialize in Specialize in

manual manual assessment and assessment and treatment of treatment of musculoskeletal musculoskeletal problemsproblems

PedorthotistPedorthotist – Make & advise Make & advise

orthotic orthotic devices, shoes, devices, shoes, bracesbraces

What is running?What is running?

One leg hoppingOne leg hopping

Leg absorbs forceLeg absorbs force

Requires flexibilityRequires flexibility

Requires hip girdle Requires hip girdle strengthstrength

Lengthening Lengthening ContractionContraction– Most damaging to muscle Most damaging to muscle

and requires great and requires great strengthstrength

– Fatigue?Fatigue?

Running Injury PreventionRunning Injury Prevention

Injury Risk FactorsInjury Risk FactorsExtrinsic Extrinsic factorsfactors– Training errorsTraining errors– EquipmentEquipment

Shoe typeShoe typeShoe ageShoe age

– EnvironmentEnvironmentSurface typeSurface typeCamberCamberDirectionDirection

Intrinsic factorsIntrinsic factors– Bone alignmentBone alignment– Muscle imbalanceMuscle imbalance– Biomechanical deficitsBiomechanical deficits

Kinetic Chain Kinetic Chain FocusFocus

Proximal segments can Proximal segments can influence distal influence distal segment motionsegment motion

Distal segments can Distal segments can influence proximal influence proximal segment motionsegment motion

Christopher M. Powers, PT, PhD JOSPT November 2003 Vol. 33 No. 11 The Influence of Altered Lower-Extremity Kinematics on Patellofemoral Joint Dysfunction: A Theoretical Perspective

Causes of InjuryCauses of Injury

Trauma (less common)Trauma (less common)

OveruseOveruse– ““Too Much Too Soon Too Too Much Too Soon Too

Fast”Fast”– Asymmetries Asymmetries

Previous injury Previous injury

Inflexibility/strength Inflexibility/strength differencesdifferences

Terrain (cambered/hills)Terrain (cambered/hills)

Training ErrorsTraining Errorstoo much, too soon, too fasttoo much, too soon, too fastIncreased injury rate beyond 20 Increased injury rate beyond 20 miles/weekmiles/week

Inadequate warm-upInadequate warm-up

Inadequate flexibility and strengthInadequate flexibility and strength

Inadequate rest between runsInadequate rest between runs

Too many miles, too soonToo many miles, too soon

Too much interval/speed trainingToo much interval/speed training

Running InjuriesRunning Injuries

Proper diagnosis of injuryProper diagnosis of injury

Understand goalsUnderstand goals

Treat underlying causeTreat underlying cause

Treat kinetic chainTreat kinetic chain

Make sense, be functionalMake sense, be functional

Injury EvaluationInjury Evaluation

History of History of problemproblemBiomechanical Biomechanical evaluationevaluationSite-specific Site-specific evaluationevaluationRunning Running assessmentassessmentShoe Shoe assessmentassessment

Common Injuries/ProblemsCommon Injuries/Problems

Hips/KneesHips/Knees– Patellofemoral PainPatellofemoral Pain– Iliotibial Band PainIliotibial Band Pain– Greater Trochanteric Greater Trochanteric

BursitisBursitisFeet/AnklesFeet/Ankles– Plantar FasciitisPlantar Fasciitis– Achilles tendonitisAchilles tendonitis““Shin Splints”Shin Splints”Stress Stress Reaction/FracturesReaction/FracturesHydrationHydration

Hip & Knee Pathology

Patellofemoral Pain Patellofemoral Pain ““Runner’s Knee”Runner’s Knee”

Pain located Pain located beneath and/or beneath and/or around knee caparound knee cap

Softening and Softening and compression of compression of cartilage under the cartilage under the knee capknee cap

>25% incidence in >25% incidence in athletesathletes

Females > MalesFemales > Males

Patellofemoral PainPatellofemoral PainVague, achy pain Vague, achy pain in front part of in front part of kneeknee

Worse with going Worse with going downstairsdownstairs

Pain when knee Pain when knee bent for long time bent for long time (like in the movie (like in the movie theatre)theatre)

Worse with hillsWorse with hills

Careful physical examinationCareful physical examination

Biomechanical evaluationBiomechanical evaluation

Running gait evaluation Running gait evaluation

X-rays usually normal in X-rays usually normal in mild/early casesmild/early cases

MRI if not getting better MRI if not getting better

Patellofemoral PainPatellofemoral PainEvaluationEvaluation

Understanding FunctionUnderstanding FunctionAbnormal knee cap tracking, abnormal alignmentKnee cap runs on femur “like train on tracks”

Patellofemoral PainPatellofemoral PainCausesCauses

Weak hip and core Weak hip and core muscles cause knee muscles cause knee cap to track improperlycap to track improperly

Tight quadricepsTight quadriceps

Overpronation of the Overpronation of the footfoot

Rigid footRigid foot

Patellofemoral PainPatellofemoral PainWhat do you do when you have it?What do you do when you have it?

Initial Treatment “PRICE”Initial Treatment “PRICE”

PProtectionrotection

RRelative Rest (& Gentle elative Rest (& Gentle Mobility)Mobility)

IIcece

CCompressionompression

EElevationlevation

Patellofemoral PainPatellofemoral Pain What do you do when you have it?What do you do when you have it?

Training modificationTraining modification

Knee bracing as Knee bracing as prescribedprescribed

Patellar mobilization, Patellar mobilization, manual therapymanual therapy

Ice regularlyIce regularly

Patellofemoral PainPatellofemoral PainWhat do you do when you have it?What do you do when you have it?

Patellar taping: a Patellar taping: a transitional steptransitional step– to encourage more force to encourage more force

from quadriceps, help from quadriceps, help with painwith pain

Flexibility: ITB, hip Flexibility: ITB, hip flexors, hamstrings, flexors, hamstrings, quadriceps, calfquadriceps, calf– Quadriceps flexibility- Quadriceps flexibility-

emphasis on lower back emphasis on lower back positionposition

Patellofemoral Patellofemoral PainPain

Additional remedies Additional remedies known to work!known to work!

Chopart strapChopart strap

Quad and ITB MassageQuad and ITB Massage

Change shoesChange shoes– get the right type for get the right type for your your

footfoot

OrthoticsOrthotics

BalanceBalance

Iliotibial Band SyndromeIliotibial Band Syndrome

Localized Localized tenderness on the tenderness on the outside of the kneeoutside of the knee

Especially common Especially common when training for when training for longer distances longer distances ~runs over 18 ~runs over 18 milesmiles

Iliotibial Band SyndromeIliotibial Band Syndrome

ITB passes over outside of femur ITB passes over outside of femur bone bone Repetitive motion causes rubbing Repetitive motion causes rubbing and inflammationand inflammation– Most friction when knee is bent Most friction when knee is bent

20-30 degrees 20-30 degrees

Iliotibial Band SyndromeIliotibial Band SyndromeCausesCauses

Flat feet with no motion control shoesFlat feet with no motion control shoes

High arches with excessive supinationHigh arches with excessive supination

Due to hip girdle weakness and/or Due to hip girdle weakness and/or tightnesstightness

Leg length differenceLeg length difference

Banked terrain, hills & stairsBanked terrain, hills & stairs

Increased mileage?Increased mileage?

Iliotibial Band SyndromeIliotibial Band Syndrome What do you do when you have it?What do you do when you have it?

Initial Treatment “RICE”Initial Treatment “RICE”

RRelative Rest elative Rest

IIcece

CCompressionompression

EElevationlevation

Iliotibial Band SyndromeIliotibial Band Syndrome What do you do when you have it?What do you do when you have it?

Anti-inflammatoriesAnti-inflammatories

Soft tissue Soft tissue mobilization/massagemobilization/massage

Foam roll mobilizationFoam roll mobilization

UltrasoundUltrasound

StretchingStretching

Multi-planar Multi-planar strengtheningstrengthening

Motion control shoesMotion control shoes

Shorten stride lengthShorten stride length

Trochanteric BursitisTrochanteric Bursitis

Pain over outer hipPain over outer hip

May radiate down May radiate down outside of thighoutside of thigh

Back or deeper hip Back or deeper hip problem?problem?

Pain laying on sidePain laying on side

Increased frequency in Increased frequency in running or contact running or contact sportssports

Females>MalesFemales>Males

Trochanteric BursitisTrochanteric BursitisCausesCauses

Direct impact or fallDirect impact or fall

Repetitive friction of Repetitive friction of glut med or ITBglut med or ITB

Leg length Leg length discrepancydiscrepancy

Hip weaknessHip weakness

Lateral hip surgeryLateral hip surgery

Trochanteric BursitisTrochanteric Bursitis What do you do when you have it?What do you do when you have it?

Initial TreatmentInitial Treatment

Relative RestRelative Rest

Ice Ice

Anti-Anti-inflammatoriesinflammatories

StretchingStretching

Trochanteric BursitisTrochanteric BursitisTreatment: Medical ManagementTreatment: Medical Management

ITB Massage/MobilizationITB Massage/Mobilization

UltrasoundUltrasound

Ice/Heat contrast Ice/Heat contrast

Multi-planar strengtheningMulti-planar strengthening

Cortisone shotCortisone shot

Hip & Knee PathologyHip & Knee PathologyTreatmentTreatment

Thorough Assessment of:Thorough Assessment of:

Biomechanical Biomechanical factorsfactors– InflexibilityInflexibility– StrengthStrength– EnduranceEndurance– Foot structureFoot structure

Training errorsTraining errors

Hip & Knee PathologyHip & Knee PathologyTreatmentTreatment

Gluteal strengthening in Gluteal strengthening in multiple planesmultiple planesFunctional Functional strengthening, control strengthening, control “track”“track”Bracing as neededBracing as neededQuadriceps Quadriceps strengtheningstrengtheningGradual return to Gradual return to runningrunning

Avoid running hills & stair climbing

Hip & Knee PathologyHip & Knee PathologyTreatmentTreatment

Strengthening hip & knee stabilizing Strengthening hip & knee stabilizing muscles in multiple angles muscles in multiple angles – single leg squats- emphasis knee single leg squats- emphasis knee

mechanics and lumbar spine position- mechanics and lumbar spine position- pelvic stabilitypelvic stability

– stair pelvic drop- emphasis on lumbar stair pelvic drop- emphasis on lumbar spine positionspine position

Gluteal StrengtheningGluteal Strengthening

““The Matrix”The Matrix”

““Power Runner”Power Runner”

Gluteal Strengthening & Balance – Gluteal Strengthening & Balance – Exercises that Mimic FunctionExercises that Mimic Function

Hip & Knee PathologyHip & Knee PathologyAlternate Exercise OptionsAlternate Exercise Options

Cross training with:Cross training with:Low-resistance cycling or spinningSwimmingPool runningElliptical

Hip & Knee PathologyHip & Knee PathologyHow to prevent its reoccurrence?How to prevent its reoccurrence?Maintain multiplanar Maintain multiplanar functional gluteal strength – functional gluteal strength – “The Matrix” in routine “The Matrix” in routine workout 1-2x/weekworkout 1-2x/week

Preserve flexibility, Preserve flexibility, especially quadricepsespecially quadriceps

Slow, progressive return to Slow, progressive return to activityactivity

Rely on gluteal muscles Rely on gluteal muscles more than quadriceps for more than quadriceps for stair climbing and squattingstair climbing and squatting

Continue cross-trainingContinue cross-training

Foot & Ankle Pathology

Plantar FasciitisPlantar Fasciitis

Common cause Common cause of heel painof heel painPain in the arch Pain in the arch or near heel on or near heel on bottom of footbottom of footWorst with 1Worst with 1stst am stepam step

Plantar FasciitisPlantar FasciitisCausesCauses

High arched and “flat feet”High arched and “flat feet”Tight plantar fasciaTight plantar fasciaTight & weak calf musclesTight & weak calf musclesTight hip flexorsTight hip flexorsIncrease in mileageIncrease in mileageIncrease in weightIncrease in weightInadequate shock Inadequate shock absorption of the heel absorption of the heel (shoe wear!)(shoe wear!)

Plantar FasciitisPlantar FasciitisWhat do you do if you have it?What do you do if you have it?

Ice (water bottle)Ice (water bottle)

Anti-inflammatoriesAnti-inflammatories

Golf/tennis ball massageGolf/tennis ball massage

Resting night splint, Ace Resting night splint, Ace wrapwrap

High top shoes or hiking High top shoes or hiking bootsboots

Orthoses/Heel cups/TapingOrthoses/Heel cups/Taping

InjectionInjection

AchillesTendonitisAchillesTendonitis

If Chronic then called If Chronic then called TendonopathyTendonopathyPain in back of heelPain in back of heelBump present?Bump present?Pain with push-offPain with push-off

AchillesTendonitisAchillesTendonitis Causes

Increased activity level &/or Increased activity level &/or less recovery timeless recovery time

OverpronationOverpronation

Tight hamstrings and heel Tight hamstrings and heel cordscords

High arched feetHigh arched feet

Weak calvesWeak calves

Frequently wearing high heelsFrequently wearing high heels

Achilles Tendonitis Achilles Tendonitis What do you do when you have it?What do you do when you have it? Relative restRelative restAnti-inflammatoriesAnti-inflammatoriesIceIceShort term Short term immobilization immobilization (splinting or bracing)(splinting or bracing)StretchingStretchingEccentric or Negative Eccentric or Negative strengtheningstrengtheningHeel liftsHeel lifts

Foot & Ankle Pathology TreatmentTreatment

Improve lower limb flexibility, Improve lower limb flexibility, especially calvesespecially calves

Multi-planar balance exercisesMulti-planar balance exercises– Single Leg StanceSingle Leg Stance

Static HoldStatic Hold

Dynamic ReachesDynamic Reaches

Foot & toe strengtheningFoot & toe strengthening– Towel ScrunchingTowel Scrunching

Calf Stretching & StrengtheningCalf Stretching & Strengthening

Calf Stretch & StrengtheningCalf Stretch & Strengthening

““Stomp the Bug”Stomp the Bug”

““Shin Splints”Shin Splints”(Medial Tibial Stress Syndrome)(Medial Tibial Stress Syndrome)

Pain located on the Pain located on the front or inside of shinfront or inside of shin

Overuse tendonitis of Overuse tendonitis of posterior/anterior posterior/anterior tibialis, soleus musclestibialis, soleus muscles

““Shin Splints”Shin Splints”CausesCauses

Overpronation during gait Overpronation during gait cyclecycle

Rigid footRigid foot

Weak lower leg musclesWeak lower leg muscles

Increase of mileage, speed Increase of mileage, speed or new runneror new runner

Improper shoe wearImproper shoe wear

“Shin Splints”

What else could it be?What else could it be?– Stress reaction of boneStress reaction of bone– Stress fracture of tibia boneStress fracture of tibia bone– Referred pain from kneeReferred pain from knee

or spineor spine– Compartment syndromeCompartment syndrome

““Shin Splints”Shin Splints” TreatmentTreatment

Relative restRelative restCrutches if pain is present at rest Crutches if pain is present at rest or with normal walkingor with normal walkingIcingIcingStretchingStretchingReturn to activity gradually (after Return to activity gradually (after pain free period)pain free period)– Training should start at 50% of pre-Training should start at 50% of pre-

injury distance and intensityinjury distance and intensity– Soft, level surfacesSoft, level surfaces

Orthotics (to correct Orthotics (to correct overpronation)overpronation)Surgery (in resistant cases)Surgery (in resistant cases)

Stress FracturesStress Fractures

Distance Distance (>20Miles/week)(>20Miles/week)

Usually worse with Usually worse with activityactivity– Worse as run progressesWorse as run progresses

Better with restBetter with rest

Potential for devastating Potential for devastating injuryinjury

Can occur in hip, thigh, Can occur in hip, thigh, or shinor shin

Stress FracturesStress Fractures ExaminationExamination

Bony tendernessBony tenderness

Common areas-Common areas-shins, hips, feet, shins, hips, feet, thigh, pelvisthigh, pelvis

X-Rays notoriously X-Rays notoriously negative negative

MRI/Bone Scan MRI/Bone Scan better testbetter test

Stress FracturesStress FracturesTreatmentTreatment

Depends on locationDepends on location– Likely immobilization or Likely immobilization or

bracingbracing

Most heal with relative Most heal with relative restrest– cross train/water cross train/water

running/swimrunning/swim

Some require surgical Some require surgical interventionintervention

Pain does not go away during the runPain does not go away during the run

Hurts every step of the runHurts every step of the run

Hurts even when walkingHurts even when walking

Hurts with single leg hopHurts with single leg hop

If you have risk factors: eating If you have risk factors: eating disorder, poor calcium diet, prior disorder, poor calcium diet, prior stress fractures, female, osteoporosis stress fractures, female, osteoporosis in the familyin the family

Stress FracturesStress FracturesRecognize the SymptomsRecognize the Symptoms

– Simple rest and ice is not Simple rest and ice is not alleviating your painalleviating your pain

– You are unable to train at the You are unable to train at the intensity you desireintensity you desire

– You are limited in your day to You are limited in your day to day activities because of your day activities because of your painpain

– Joint swelling is your body Joint swelling is your body telling you something is wrong; telling you something is wrong; this should be medically this should be medically evaluatedevaluated

– We all get aches and pains with We all get aches and pains with running, but if your pain is running, but if your pain is persistent, this should be persistent, this should be medically evaluatedmedically evaluated

Running InjuriesRunning InjuriesWHEN TO SEE THE DOCTOR:WHEN TO SEE THE DOCTOR:

Fluid IntakeFluid Intake

FactsFacts

Water composes 50-Water composes 50-70% body weight70% body weight

Typical water intake is Typical water intake is 2.4L/day2.4L/day

Requirements vary Requirements vary depending on temp, depending on temp, humidity, activityhumidity, activity

Water deficits of 5-7% Water deficits of 5-7% are assoc w/ dyspnea, are assoc w/ dyspnea, HA, and apathyHA, and apathy

FactsFacts

Sweat rate is Sweat rate is approximately 500-approximately 500-2000cc/hr in athletes2000cc/hr in athletesAthletes typically Athletes typically consume only half of consume only half of fluid lossesfluid lossesLeads to ~3% (2-3lbs) Leads to ~3% (2-3lbs) weight loss in 4 hours weight loss in 4 hours

Water RequirementsWater Requirements

Lose 2-5% weight Lose 2-5% weight during moderately during moderately intense activity- intense activity- roughly 1.5 Lroughly 1.5 L

Typical sweat rates Typical sweat rates 1L/hr1L/hr

Theoretically, Theoretically, dehydration risk factor dehydration risk factor for heat illnessfor heat illness

Consequences of water Consequences of water imbalanceimbalance

If deficit exceeds 2%, If deficit exceeds 2%, performance performance compromisedcompromised

Increase 1 ºC body Increase 1 ºC body temp for each 1% body temp for each 1% body weight lossweight loss

Overhydration no Overhydration no benefit-possibly benefit-possibly detrimentaldetrimental

ElectrolytesElectrolytes

Sweat is hypotonicSweat is hypotonic

Sodium generally 10-Sodium generally 10-30meq/L30meq/L

As sweat rate As sweat rate increases, increases, concentration of concentration of sodium increasessodium increases

AND-----AND----- with heat with heat acclimatization sweat acclimatization sweat rate increases. rate increases.

Hence theoretical Hence theoretical increased salt lossesincreased salt losses

ElectrolytesElectrolytes

Salt supplements do Salt supplements do not improve not improve performance or heat performance or heat tolerancetoleranceCramps felt to be Cramps felt to be related to electrolytes related to electrolytes but never provenbut never provenCurrently sodium Currently sodium supplementation not supplementation not recommended-GI recommended-GI discomfortdiscomfort

HydrationHydration

Sweating rate is Sweating rate is approximately 500-2000cc/hr approximately 500-2000cc/hr in runnersin runners

500cc fluid before exercising, 500cc fluid before exercising, 300cc every 20 minutes300cc every 20 minutes

evidence to suggest that evidence to suggest that consumption of a low consumption of a low carbohydrate drink during carbohydrate drink during prolonged and intermittent prolonged and intermittent exercise will improve exercise will improve performance (No one type is performance (No one type is superior to the other)superior to the other)

Sport drink comparisonSport drink comparison

RecommendationsRecommendations

If exercising less than 50 minute, benefits If exercising less than 50 minute, benefits of drinking questionableof drinking questionable

Heat injury may be more related to Heat injury may be more related to intensity of exerciseintensity of exercise

Recommendations of fluid intake more for Recommendations of fluid intake more for those athletes participating longer than 1 those athletes participating longer than 1 hourhour

Supplemental salt intake if greater than 4 Supplemental salt intake if greater than 4 hours activityhours activity

RecommendationsRecommendations

If activity less than 90 minutes, use If activity less than 90 minutes, use waterwater

But 6-8% CHO has been shown to But 6-8% CHO has been shown to sustain better power output after 60 sustain better power output after 60 minutes, so it may improve minutes, so it may improve performance particularly if no other performance particularly if no other nourishmentnourishment

Plus sports drinks may taste betterPlus sports drinks may taste better

Running InjuriesRunning InjuriesConclusionConclusion

Proper diagnosis of Proper diagnosis of injuryinjury

Understand goalsUnderstand goals

Treat underlying Treat underlying causecause

Treat kinetic chainTreat kinetic chain

Be sport specificBe sport specific

Make sense, be Make sense, be functionalfunctional

“If I knew that I was going to live this long, I would have taken better care of myself”-Mickey Mantle