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Running Injury Mechanics: What Really Matters

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Running Injury Mechanics: What Really Matters Running Injury Mechanics: What Really Matters Bryan Heiderscheit, PT, PhD UW Neuromuscular Professor Biomechanics Orthopedics and Rehabilitation Lab Biomedical Engineering Director, UW Runners’ Clinic Director, Badger Athletic Performance Research Co-director, UW Neuromuscular Biomechanics Lab NYC Marathon 1970 early 1990s UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 1 of 96 and should not be reproduced without permission Running Injury Incidence ~65% of runners experience annual injury Lysholm and Wiklander (1987) Am J Sports Med Incidence in those training for marathon as high as 90% Satterthwaite et al. (1993) Br J Sports Med Experienced runners are less frequently injured Marti et al (1988) Am J Sports Med; Taunton et al. (2003) Br J Sports Med UW Neuromuscular Biomechanics Lab Location of Injury Other 10.8% Achilles/Calf 5 most common injuries 6.4% Patellofemoral pain Knee syndrome Hip/Pelvis 42.1% Iliotibial band friction 10.9% syndrome Plantar fasciitis Tibial stress fracture Lower Leg 12.8% Knee meniscal injuries Foot/ankle 16.9% Taunton et al. (2002) Br J Sports Med UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 2 of 96 and should not be reproduced without permission Why are Running Injuries so Common? 2 commonly cited mechanisms: 1. Excessive and repetitive impacts too much energy for the body to safely absorb 2. Excessive or prolonged pronation creates abnormal loading by positioning the lower extremity in poor alignment Does evidence support these mechanisms? UW Neuromuscular Biomechanics Lab Established Risk Factors 1. Running experience no prior experience (~2.5-3x more likely to be injured) novice runners more likely to quit running following injury Buist et al. (2008) Br J Sports Med; Walter et al. (1989) Arch Intern Med 2. Weekly mileage or intensity rapid increase exceeding 40 miles/week (~3x more likely to be injured) Macera et al. (1989) Arch Intern Med 3. Previous injury incomplete recovery or pre-existing issue van Mechelen (1992) Sport Med; van Gent et al. (2007) Br J Sports Med 4. Competitive training motive likely to ignore early symptoms Marti et al. (1988) Am J Sports Med; van Mechelen (1992) Sport Med UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 3 of 96 and should not be reproduced without permission Potential Risk Factors Intrinsic Age incidence may increase with age location shifts with age Taunton et al. (2003) Br J Sports Med McKean (2006). Clin J Sport Med Gender males 1.5x more likely to be injured Buist et al. (2008) Br J Sports Med BMI females < 21 kg/m2 males > 26 kg/m2 was protective Macera et al. (1989) Arch Intern Med Taunton et al. (2003) Br J Sports Med UW Neuromuscular Biomechanics Lab Non-Risk Factors Terrain Arch height Orthotic use Cross training Warm-up Stretching Macera et al. (1989) Arch Intern Med Walter et al. (1989) Arch Intern Med Taunton et al. (2003) Br J Sports Med van Gent (2007) Br J Sports Med Buist et al. (2008) Br J Sports Med UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 4 of 96 and should not be reproduced without permission Static Alignment and Injury Lower extremity alignment is not a major risk factor for running injuries Twellaar et al. (1997) Int J Sports Med Wen et al. (1997) Med Sci Sports Exerc Michelson et al. (2002) Foot Ankle Int Taunton et al. (2002) Br J Sports Med Lun et al. (2004) Br J Sports Med Schache et al. (2005) Res Sports Med van Gent et al. (2008) Br J Sports Med Buist et al. (2008) Br J Sports Med Buist et al. (2009) Am J Sports Med UW Neuromuscular Biomechanics Lab Foot Pronation and RRI 927 novice runners in neutral shoes with mileage tracked by GPS over 1 yr and uploaded to website RRI: any musculoskeletal complaint of the lower extremity or back caused by running, which restricted the amount of running for at least 1 week. Nielsen et al. (2013) Br J Sports Med UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 5 of 96 and should not be reproduced without permission Foot Pronation and RRI The number of injuries per 1000 km of running was significantly lower among pronators than among neutrals The vast majority of foot types will experience similar injury survival after 250 km of running The results contradict the widespread belief that foot pronation is associated with an increased risk of running-related injury Nielsen et al. (2013) Br J Sports Med UW Neuromuscular Biomechanics Lab Running Impacts Determinants: DJD Body mass Stress fractures Running speed Shin splints Touchdown Cartilage breakdown kinematics LBP Shoe properties RBC breakdown and depressed iron Surface status properties/gradient UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 6 of 96 and should not be reproduced without permission Running Impact Attenuation GRFV 4 3 Force (BW) 2 active 1 passive / impact External impacts Heel- Toe-off progressively reduced strike by tissues UW Neuromuscular Biomechanics Lab Impact Attenuation Typical 4 Decreased peak Decreased peak 3 and loading rate Force (BW) 2 1 Heel-strike Toe-off UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 7 of 96 and should not be reproduced without permission Running Impacts and Surface Incline 250 Impact Peak Braking Impulse 200 Propulsion Impulse % of Level 150 (0°) 100 50 0 -9 -6 -3 0 3 6 9 downhill uphill Surface Incline (°) Gottschall and Kram (2005) J Biomechanics UW Neuromuscular Biomechanics Lab Impacts and Injury Injury-free runners display less impact peak and loading rate 2.5 100 Injury-free 90 Injured 2.2 80 t 70 1.9 60 50 1.6 BW/s 40 Body Weigh 30 1.3 20 10 1 0 Impact Peak Loading Peak Hreljac et al. (2000) Med Sci Sports Exerc UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 8 of 96 and should not be reproduced without permission Injury and Impacts prospective study (n=133); average 30 km/wk Injury Frequency (%) Nigg (2001) Clin J Sports Med UW Neuromuscular Biomechanics Lab Ground Reaction Forces Landing posture, not footwear, determines the transient impact peak Lieberman et al. (2010) Nature UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 9 of 96 and should not be reproduced without permission Why Forefoot? Rearfoot GRF Forefoot V 4 Loading Rate Associated with Active peak bone stress injuries 3 Force (BW) Active Peak 2 Less frequently studied Associated with joint 1 vertical loading moments and rate (average & compression instantaneous) Heel-strike Toe-off UW Neuromuscular Biomechanics Lab Is Loading Rate Actually Less? Boyer et al. (2014) Med Sci Sports Exerc UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 10 of 96 and should not be reproduced without permission Unpredictable Loading Rate Swing phase Stance phase R2=0.167 R2=0.04 step rate Schmitz et al. (2014). J Biomech Wille et al. (2014). J Orthop Sports Phys Ther Increased thigh position at mid swing and increased step rate are weakly associated with reduced loading rate UW Neuromuscular Biomechanics Lab Loading Rate and Foot Angle (N/kg/s) (N/kg/s) Loading Rate Loading Rate Loading Rate Rearfoot Non-Rearfoot (>0°) (≤0°) When grouped, the However, the relationship is relationship between much more complex loading rate and foot angle Loading rates appear highest appears linear with foot angles of 0° to 10° Stiffler-Joachim & Heiderscheit (in review) Med Sci Sports Exerc UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 11 of 96 and should not be reproduced without permission Loading Rate and Speed Loading rate scales with speed Non-linear relationship holds across speeds Loading Rate (N/kg/s) Loading Rate Foot Inclination Angle (°) Stiffler-Joachim & Heiderscheit (in review) Med Sci Sports Exerc UW Neuromuscular Biomechanics Lab Foot Strike Classification Forrester & Townsend, 2015 Altman & Davis, 2012 Lieberman et al, 2015 Loading Rate (N/kg/s) Loading Rate FFS MFS RFS Unpublished Data, Badger Athletic Performance Foot Inclination Angle (°) Forrester & Townsend (2015) Gait Posture UW Neuromuscular Altman & Davis (2012) Gait Posture Biomechanics Lieberman et al (2015) Plos One Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 12 of 96 and should not be reproduced without permission Injury Occurrence Preseason (healthy) 2000 mechanics measured BSI 2015-2017 Non-BSI Healthy Males and females 1500 Preferred speed RRI recorded during each 1000 season medically diagnosed 500 Injuries were distributed across loading rates 0 -15 -10 -5 0 5 10 15 20 20 No clear relationship Foot Inclination Angle at Initial Contact between foot strike and (deg, [-] indicates forefoot) injury Unpublished Data, Badger Athletic Performance UW Neuromuscular Biomechanics Lab Lower Extremity Dynamic Alignment 1. Contralateral pelvic drop 2. Femoral IR 3. Knee valgus 4. Tibial internal rotation 5. Foot pronation Powers et al. (2003) J Orthop Sports Phys Ther UW Neuromuscular Biomechanics Lab This information is the property of Bryan Heiderscheit, PT, PhD Page 13 of 96 and should not be reproduced without permission Hip Muscle Weakness Injured athletes and runners displayed hip ABD, FLEX and ER weakness Ireland et al. (2003) J Orthop Sports Phys Ther Leetun et al. (2004) Med Sci Sports Exerc Niemuth et al. (2005) Clin J Sport Med Noehren et al. (2007) Clin Biomech ITBS symptom resolution paralleled return of hip ABD strength (~20% deficit) Fredericson et al.
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