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Common Running Injuries

Common Running Injuries. Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runner’s Clinic at UVA Team Physician, Ragged Mountain Racing. Objectives. Identify common contributors to running injuries

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Common Running Injuries

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  1. Common Running Injuries Robert P. Wilder, MD, FACSMChair, Physical Medicine & RehabilitationThe University of VirginiaMedical Director, The Runner’s Clinic at UVATeam Physician, Ragged Mountain Racing

  2. Objectives • Identify common contributors to running injuries • Describe treatment for heel pain, stress fractures, and patellofemoral pain syndrome • Understand the importance of proper mechanics in managing injury • Outline criteria for running while treating injury

  3. Epidemiology of Running Injuries 30 million active runners 70% all runners sustain significant injury 40% knee 15% each: shin, achilles, hip/groin 10% foot and ankle 5% spine 25% recreational 5% elite

  4. Epidemiology of Running Injuries 4% bit by dogs 0.3% hit by bicycles 0.6% hit by cars 7% hit by thrown objects

  5. Principle of Transition“Culprits & Victims”

  6. Intrinsic Abnormalities Malalignment Muscle imbalance Inflexibility Muscle weakness Instability

  7. Extrinsic Abnormalities Training errors Equipment Environment Technique Sport-imposed deficiencies

  8. Examination of the Injured Runner History Biomechanical assessment Site-specific exam Dynamic exam Shoe exam Ancillary testing radiologic electrodiagnostic compartment testing

  9. History • Prior injury history • Team/Club • Identify transitions • MPW (20, 40) • Long run (< 1/3 weekly total) • Intensity • Surface (? Muscle tuning) • Shoes/orthotics (350-400 miles) • Cross Training • Goals • Life Stressors/fatigue • Females: eat d/o, menstrual irreg, osteopenia

  10. Physical Examination • Biomechanical assessment • Site specific examination • Dynamic examination • Ancillary testing • Shoe examination

  11. Functional Screening • Single Leg Stance • Single Leg Squat • Bilateral Squat • FHB isolation • Step-down Test • STAR Excursion Test • Swing Test

  12. Functional Screening Single Leg Stance

  13. Functional Screening Single Leg Squat

  14. Functional Screening Bilateral Leg Squat

  15. Functional Screening FHB Isolation

  16. Functional Screening Step-Down Test

  17. Functional Screening STAR Excursion Test

  18. Functional Screening Swing Test

  19. Heel Pain in Runners

  20. Plantar Fasciitis • 10% U.S. Population • 600,000 outpatient visits annually • 7-9% all running injuries

  21. Plantar Fascia • Thick aponeurosis • Arises from medial calcaneal tuberosity • Spans arch • Bands circle flexor tendons • Insert proximal phalanx

  22. Functions During Gait Cycle • Heel strike: Allows midfoot to become flexible, absorb shock, conform to uneven surface • Toe off: Windlass Mechanism: Shortening increases arch, locks midtarsal, stabilizes toe off

  23. Pathophysiology • Overuse • Inflammation • Chronic changes (collagen necrosis, angiofibroplastic hyperplasia, chondroid metaplasia, matrix calcification) • Tearing • Medial vulnerable (thin, limited vascular supply, limited ability to stretch

  24. Risk Factors • Obesity • Excessive time on feet • Limited ankle motion (tibiotalar) • Limited great toe mobility (extension) • Inflexibility (HS and achilles) • Pes cavus • Pes planus • Leg length inequality (short leg)

  25. Presentation • Plantar heel pain • A.M. pain • Mid arch (sprinters) • Increased pain with running • Imaging primarily to rule out other causes

  26. Treatment • Relative Activity Modification • Anti-inflammatories • Flexibility (HS, gastroc-soleus, plantar fascia) • Manual therapy (ankle and great toe mobility: tibiotalar subtalar, great toe) • Strength (Foot intrinsics, ankle stability, lower quarter stability)

  27. Treatment (cont) • Devices – CTF brace, heel cushions • Low dye taping • Night splints and socks • Inserts • Steroid injections

  28. Treatment (cont) • ESWT (> 12 mos) • Botulinum A • Autologous blood • PRP • Prolotherapy

  29. Recalcitrant Cases • Confirm diagnosis • Surgical release • 75-95% “some improvement” • 27% significant pain • 20% activity restriction • Fasciectomy + neurolysis of nerve to ADM • Percutaneous plantar fasciotomy • Flouroscopically-assisted fasciotomy • US guided fasciotomy

  30. Heel Pain Differential • Fat Pad Insufficiency • Calcaneal Stress Fracture

  31. Heel Pain Differential (cont) • Neuropathies • Tarsal Tunnel Syndrome • Medial plantar nerve (“Joggers Foot”) • First Branch, Lateral Plantar nerve (“Baxter’s Neuropathy”) • Radiculopathy

  32. Heel Pain Differential (cont) • Tendonopathies • PTTD (posterior tibial) • Flexor • Peroneal • Achilles

  33. Heel Pain Differential (cont) • Spring Ligament injury

  34. Heel Pain Differential (cont) • Bursitis • Pre-achilles • Retrocalcaneal

  35. Heel Pain Differential (cont) • OS Trigonum Syndrome (differentiate from posterior talus fracture)

  36. Heel Pain Differential (cont) • Haglund’s

  37. Heel Pain Differential (cont) • Sever’s Syndrome (kids)

  38. Heel Pain Differential (cont) • Achilles enthesopathy (consider inflammatory)

  39. Heel Pain Differential (cont) • Tarsal coalition

  40. Heel Pain Considerations • Ankle mobility (tibiotalar, subtalar great toe) • Flexibility (HS, GS, PF) • Ankle stability • Lower quarter stability

  41. Stress Fractures Failure of bone to adapt adequately to mechanical loads (ground reaction forces and muscle contraction) experienced during physical activity • Tibia • Metatarsals • Fibula • Navicular

  42. Stress Fractures - Pathophysiology

  43. Stress Fractures (cont) • Non-critical (relative rest 6-8 wks) • Medial tibia • Metatarsals 2,3,4

  44. Stress Fractures (cont) At risk fractures: • Femoral neck • Anterior tibia • Medial malleolus • Navicular • Base 5th metatarsal

  45. Femoral Neck Superior (distraction) – higher incidence worsening/ non union Inferior – (compression)

  46. Anterior Tibia Casting vs relative rest up to 6-8 months If no healing – ortho (transverse drilling, grafting, medullary fixation)

  47. Navicular • Tender N-spot • Critical zone middle 1/3 • Non-weight bearing 6-8 weeks • Progressive activity over 6 more weeks

  48. Proximal 5th Metatarsal • Jones fx of proximal diaphysis • Cast 6-10 weeks • Non-union: ortho • Consider ortho early in competitive • Contrast with avulsion: symptomatic RX

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