Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia...

transcript

Robert P. Wilder, MD, FACSMChair, Physical Medicine & Rehabilitation

The University of VirginiaMedical Director, The Runner’s Clinic at UVA

Team Physician, Ragged Mountain Racing

Common Running Injuries

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

Epidemiology of Running Injuries

30 million active runners70% all runners sustain significant injury

40% knee15% each: shin, achilles, hip/groin10% foot and ankle5% spine

25% recreational5% elite

Epidemiology of Running Injuries

4% bit by dogs0.3% hit by bicycles0.6% hit by cars7% hit by thrown objects

Principle of Transition“Culprits & Victims”

Intrinsic Abnormalities

MalalignmentMuscle imbalanceInflexibilityMuscle weaknessInstability

Extrinsic Abnormalities

Training errorsEquipmentEnvironmentTechniqueSport-imposed deficiencies

Examination of the Injured Runner

HistoryBiomechanical assessmentSite-specific examDynamic examShoe examAncillary testing

radiologicelectrodiagnosticcompartment testing

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

Physical Examination

• Biomechanical assessment• Site specific examination• Dynamic examination• Ancillary testing• Shoe examination

Functional Screening

• Single Leg Stance• Single Leg Squat• Bilateral Squat• FHB isolation• Step-down Test• STAR Excursion Test• Swing Test

Single Leg Stance

Single Leg Squat

Bilateral Leg Squat

FHB Isolation

Step-Down Test

STAR Excursion Test

Swing Test

Heel Pain in Runners

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

Plantar Fascia• Thick aponeurosis• Arises from medial

calcaneal tuberosity• Spans arch• Bands circle flexor

tendons• Insert proximal

phalanx

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

Pathophysiology

• Overuse• Inflammation• Chronic changes (collagen necrosis,

angiofibroplastic hyperplasia, chondroid metaplasia, matrix calcification)

• Tearing• Medial vulnerable (thin, limited vascular

supply, limited ability to stretch

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)

Presentation• Plantar heel pain• A.M. pain• Mid arch (sprinters)• Increased pain with

running• Imaging primarily to rule

out other causes

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)

Treatment (cont)

• Devices – CTF brace, heel cushions• Low dye taping• Night splints and socks• Inserts• Steroid injections

Treatment (cont)

• ESWT (> 12 mos)• Botulinum A• Autologous blood• PRP• Prolotherapy

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

Heel Pain Differential

• Fat Pad Insufficiency• Calcaneal Stress Fracture

Heel Pain Differential (cont)

• Neuropathies– Tarsal Tunnel Syndrome– Medial plantar nerve

(“Joggers Foot”)– First Branch, Lateral

Plantar nerve (“Baxter’s Neuropathy”)

– Radiculopathy

• Tendonopathies– PTTD (posterior tibial)– Flexor– Peroneal– Achilles

• Spring Ligament injury

• Bursitis– Pre-achilles– Retrocalcaneal

• OS Trigonum Syndrome (differentiate from posterior talus fracture)

• Haglund’s

• Sever’s Syndrome (kids)

• Achilles enthesopathy (consider inflammatory)

• Tarsal coalition

Heel Pain Considerations

• Ankle mobility (tibiotalar, subtalar great toe)• Flexibility (HS, GS, PF)• Ankle stability• Lower quarter stability

Stress FracturesFailure of bone to adapt adequately to mechanical loads (ground reaction forces and muscle contraction) experienced during physical activity

1. Tibia2. Metatarsals3. Fibula4. Navicular

Stress Fractures - Pathophysiology

Stress Fractures (cont)

• Non-critical (relative rest 6-8 wks)• Medial tibia• Metatarsals 2,3,4

Stress Fractures (cont)

At risk fractures:– Femoral neck– Anterior tibia– Medial malleolus– Navicular– Base 5th metatarsal

Femoral Neck

Superior (distraction) – higher incidence worsening/ non union

Inferior – (compression)

Anterior Tibia

Casting vs relative rest up to 6-8 months

If no healing – ortho (transverse drilling, grafting, medullary fixation)

Navicular• Tender N-spot• Critical zone middle 1/3• Non-weight bearing 6-8

weeks• Progressive activity

over 6 more weeks

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

Patellofemoral Syndrome• Pain associated with the

articular surface of the patella and femoral condyles, its alignment and motion

• “Runners Knee” #1 presenting complaint to Runner’s Clinics

• #1 cause lost time in basic training military recruits

PFS - Classification

• Patellofemoral instability• PFS with malalignment• PFS without malalignment

PFS – Contributing Factors

• Bony abnormalities• Malalignment • Soft tissue abnormalities

PFS – Bony Abnormalities

• Dysplasia of femur

• Asymetry of patellar facets

PFS – Lower Extremity Malalignment

• Femoral anteversion• Increased Q angle• Knee valgus (knock kneed)• Lateral patellar tilt• Lateral tibial tuberosity• Abnormal tibial torsion• Hyperpronation• Restricted dorsiflexion

PFS – Muscle/Soft Tissue Imbalances

• Weak, delayed activation VMO• Weak quads• Tightness Quads, ITB, hamstring, gastroc• Weak hip muscles , abductors, gluts

Patellofemoral Syndrome - Diagnosis

• Anterior, peripatellar, subpatellar pain• Downhill and downstairs• Theater sign• Contributing factors• Apprehension (shrug) sign• X-ray

Patellofemoral Syndrome - Treatment

• Correct the functional deficits!• Bracing, taping• Foam roller• Correct pronation (if excessive)• Adjust training – avoid hills, bike mod• Correct the functional deficits!

• Lots of options (a good thing)• Can affect impact forces, loading rates, torque forces• ? Relation to shoes, form or both• Rarely does “one size fit all”• If it ain’t broke, don’t fix it?• All transitions gradual• With barefoot, minimalist ensure stability and form

• Cross train (aqua run, eliptical bike)• Walk, then walk – jog, then run• 10% per week rule• Long run increases no more than 2 miles

Relative Activity Modification Guidelines

Rule #1

• If you feel mild pain (0-3/10): it is OK to run• If you feel moderate pain (4-6/10): reduce activity

until pain level is mild.• Severe pain (> 7/10): no running

Rule #2

• Pain that decreases with activity is OK.• Pain that gets worse with activity is bad; time

to reduce or stop activity.

Rule #3

• No limping allowed.• If the pain alters your gait pattern, it is time to

reduce or stop the activity until you have normal biomechanics.

Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia...

Documents