Running Injuries Bill Wiley ORV July 24, 2003. Introduction Approximately 30 million Americans run...
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![Page 1: Running Injuries Bill Wiley ORV July 24, 2003. Introduction Approximately 30 million Americans run for recreation or competition (Novachek 1998) Running.](https://reader036.fdocuments.us/reader036/viewer/2022062516/56649e5d5503460f94b55c2d/html5/thumbnails/1.jpg)
Running Injuries
Bill Wiley
ORV
July 24, 2003
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Introduction
• Approximately 30 million Americans run for recreation or competition (Novachek 1998)
• Running is Not for Everyone (certain body types are contraindicated)
• Pre-existing conditions cause many injuries• Some should be directed to other activities• Runners are tough and usually exhaust self-help
remedies
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Classification/Levels
• Lutter Clin Sp Med 1985– Level 1 (Jogger/Recreational) - <10 miles/wk– Level 2 (Sports Runner) – 10 to 30 miles/wk– Level 3 (Long Distance) – 30 to 60 miles/wk– Level 4 (Elite Marathoner) – 60 to 180 miles/wk
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Gait Cycle
• Definition: Period from initial contact of one foot until the contact of that same foot.
• 2 Phases:– Stance Phase – foot is touching ground– Swing Phase – foot is not touching ground
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Gait Cycle
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Gait Cycle
• Percentage of Stance Phase– Standing 100%– Walking 60%– Running 31%– Sprinting 22%
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Kinematics
• Pelvis, Femur and Tibia IR during early Stance Phase (heel strike)– Eversion and Unlocking of the subtalar joint
which allows a more supple foot for shock absorption
• At Toe-Off there is ER of pelvis, femur and tibia – Inversion and Locking of subtalar joint which
makes it more rigid for energy transfer
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Kinematics
• Differences btwn Running and Walking– ROM increases as velocity increases– Body lowers center of gravity w/increased
speed– Walking Heel contacts the ground first– Running usually contact posterolateral foot– Running has a double float phase (Swing)– Walking has a double support phase (Stance)
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Kinetics
• Vertical Ground Reaction Force– Walking 1.3 to 1.5 times body weight– Running 3 to 4 times body weight
• During running the forces are occuring at least twice as fast, therefore the increased strain on the skeletal and soft tissues is not 2, but a 4-fold increase
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Kinetics
• Assuming a stride length of 4.5 feet, a runner will take 1,175 steps per mile.
• Therefore a Marathon runner could take over 30,000 steps
• If impact is 250% of body weight and weigh 150 lbs then the runner absorbs 110 tons on each foot per mile (220,000 lbs)
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Beach’s 6 S’s of Running
• Structure (a predisposing body type)
• Shoes (Worn out or improper type)
• Surface (Uneven, hard)
• Strength (weak muscles)
• Stretching (not allowing enough warmup)
• Sudden Change (increased too fast or even
not giving body enough rest)
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Specific Problems
• Overuse
• Stress Fractures
• Exertional Compartment Syndrome
• Specific Injuries– Sprained Ankle– Torn Meniscus
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Overuse
• Iliac Crest Apophysitis• Iliotibial Band
Syndrome• Patellofemoral
Syndrome• Patellar Tendonitis• Shin Splints
• Achilles Tendonitis• Posterior Tibial
Tendonitis• Peroneal Tendomitis• Plantar Fasciitis• Turf Toe
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Patellofemoral Syndrome
• Most Common Knee Problem• Mechanical features that predispose
– Femoral Anteversion– Valgus Knees– Pronated foot
• Other Risk Factors– Weak Quads– Tight Hamstrings– Overweight– Female
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Patellofemoral Syndrome
• Treat by strengthening quads
• Stretching Hamstrings
• Ice
• NSAIDs
• Possibly Orthotics
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Iliotibial Band Friction Syndrome
• Runners Knee
• Most common problem on lateral side of knee
• Initiated by a long run and aggravated by running downhill or on a slant
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Iliotibial Band Friction Syndrome
• Pathology is the IT band rubbing over the Lateral femoral condyle
• Abductor Fatique and Weakness contribute as well as prolonged varus stress
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Iliotibial Band Friction Syndrome
• Exam findings are tenderness over the distal ITB and LFC
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Iliotibial Band Friction Syndrome
• Treatment– Ice – NSAID’s– Capsaicin cream and friction message– Stretching– Activity modification– Rarely surgical release of the posterior 2 cm of
the ITB
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Stress Fractures
• Pars Interarticularis
• SI joint
• Pelvis
• Femoral Neck
• Tibia
• Fibula
• Metatarsal
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Stress Fractures
• Frequency by location (Renstrom ICL 1993)– Tibia 34%– Fibula 24%– Metatarsals 18%– Femur 14%– Pelvis 6%– Others 4%
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Stress Fractures
• Can Take 2 to 4 weeks before the xray is positive
• Bone Scan and MRI for earlier detection
• Bone Scan may remain hot for 14 to 24 months so be careful in using as a tool to RTS
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Femoral Neck Stress Fractures
• Pain and achiness in groin, anterior thigh or knee• Often an antalgic gait• 4 to 10x’s more common in females (Jones 1989)• 2 types (Devas JBJS 1965)
– Compression (more common in young pts)• Inferior part of neck
– Distraction (more common in older pts)• Superior part/Tension side of neck
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Femoral Neck Stress Fractures
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Femoral Neck Stress Fractures
• Treatment– Any displacement Fix– Nondisplaced Compression, NWB w/crutches
and rest until pain-free (4 – 6 wks)– Distraction type – tx w/Internal Fixation
acutely
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Jones Fracture
• 75% of chronic fractures occur in patients between 15 and 21 yoa and most are male.
• Cavus Foot is more likely b/c increased loads on outside edge and is a more rigid foot
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Jones Fracture
Blood Supply is poor to the base of the Fifth MT (Shereff et al Foot Ankle 1991)
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Treated with 4.5 mm cannulated Herbert Whipple Screw
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Exertional Compartment Syndrome
• History– Pain, achiness or tightness after activity– Relieved with rest– May have numbness, paraesthesia or weakness– Most commonly affects the anterior
compartment but has been described in all 4– 75 to 90% have Bilateral symptoms
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CECS
• Physical Exam– Often no abnormality is found– 20 to 60% have a muscle hernia (13% normal
have this as well)• Occurs in the distal anterior compartment where
the superficial peroneal nerve exits the fascia
– May have tightness or fullness if exercised soon before exam
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• 15 yo WF c/o Left leg pain while training for basketball. Pain for 8 months
• Xrays negative
EJ
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EJ
Rest 5 min 15 min
Ant 21 23 --
Lat 22 42 30
DP 11 12 --
SP 9 8 --
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CECS
• Testing– Xrays and Bone Scan to R/O Stress Fractures– Compartment Pressure Monitoring (Pedowitz
AJSM 1990)• Pre-exercise > 15 mmHg
• 1 minute Post > 30 mmHg
• 5 minute Post > 20 mmHg
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Leversedge AJSM 2002 – superficial peroneal nerve pierces fascia 13.5 cm (range of 8 – 17.5 cm) from tip of distal fibula
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EJ
• One week later patient underwent Anterior and lateral compartment release by way of 2 incision technique
• Patient is back to training with no pain
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Chronic Ankle Instability
• Mechanical Instability– Anterior Translation
• Over 10 mm on one side or over 3 mm side to side difference
– Talar Tilt• Over 9 degrees on one side or more than 3 degrees
side to side difference
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Chronic Ankle Instability
• Functional Instability– A subjective feeling of the ankle giving way
during physical activity or during simple everyday activities after a sprain
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Chronic Ankle Instability
• Treatment Options– Therapy will help a significant portion– Direct Repair (Brostrum)– Tenodesis (Chrisman-Snook, Watson-Jones)– Ligament Reconstruction
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DB
• 25 yo WF with chronic ankle sprains and catching and locking in her Right ankle
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DB
• The patient was taken to the OR for diagnostic ankle arthroscopy
• The leg was placed in an arthroscopic leg holder with the tourniquet as high up and the leg brought down as far as possible
• Nothing was seen from the anterior portals, but there was significant synovitis
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DB
• A posterolateral portal was made and the probe identified a large loose body which was removed with a grasper.
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Ankle Impingement
• Bony Impingement– “Soccer Players Ankle”
• Osteophytes on the anterior rim of the tibia where the soft tissues get trapped between the tibia and talus during dorsiflexion
• Felt to be due to a traction injury to the capsule when the foot is repeatedly forced into extreme plantar flexion
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Ankle Impingement
• Bony Impingement– Usually develops over a period of 10 yrs or
more– Occurs in soccer, dancing, running, basketball
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Ankle Impingement
• Bony Impingement– May have swelling and tenderness anteriorly– Pain with dorsiflexion– Exostosis on lateral xrays– Forced Dorsiflexion lateral may show
osteophytes or a divot sign (divot in the anterior talus allowing the osteophyte room to engage)
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Ankle Impingement
• Bony Impingement– Treatment is ankle arthroscopy and
excision of the osteophyte
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Ankle Impingement
• Soft-Tissue Impingement– Meniscoid Lesion (Ferkel Lesion – AJSM
1991)• Persistent Anterolateral Ankle pain after an
inversion injury and sprain
• Hypertrophied synovium or a torn end of the ATFL becomes entrapped on dorsiflexion
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Ankle Impingement
• Soft-Tissue Impingement– Typically no evidence of instability on exam– Pain with Dorsiflexion– Pain in the anterolateral border of the ankle– Relief of symptoms with injection
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Ankle Impingement
• Soft-Tissue Impingement– Treatment is ankle arthroscopy and resection of
the lesion
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