Running Injuries

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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
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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

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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

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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

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Gait and Foot Strike are Variables
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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

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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

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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

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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

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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

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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

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Common Running Injuries

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

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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

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Goals for Running Injury

• PFSS
• ITB
• Achilles Tendonosis
• MTSS/ Tibial Stress Fx
• High Risk Stress Fxs

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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

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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

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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

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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)

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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

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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

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Methods

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

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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

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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

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Dynamic Genu Valgus
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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

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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

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Eccentric Strength Exercises for Achilles Injury
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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

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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

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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

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Tibial Stress Fracture/ Exam

• Direct tenderness
• Pain on tuning fork
• Positive hop test
• Swelling

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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

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High Risk Stress Fractures

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

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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

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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

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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

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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

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