Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Rehabilitation of the Injured Runner

• Education Rehabilitation of the Injured Runner: • Pain relieving modalities Addressing Mechanics • Taping/bracing/orthotics • Manual Therapy Jason B. Lunden, PT • Strengthening Board Certified Specialist in Sports Physical Therapy Excel Physical Therapy • Neuromuscular control Bozeman, MT • Training

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Objectives Phases of the gait cycle

• Review the basic of running

• Describe examples of pathomechanics associated with running injuries

• Demonstrate how physical therapists address the pathomechanics of running and the treatment of the injured runner

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Measures of the Running Gait Cycle Phases of Running Gait Cycle

• Impact: up to 3x BW

• first 50% of stance phase = greatest eccentric load

• 3 main strike patterns: • Stride Length: the distance between contact – Heel points of the same foot – Midfoot • Step Length: the distance between foot contact points – Forefoot between feet • Cadence: the number of steps per minute

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 1 Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Biomechanics Review

• GRF-the force of the ground on the foot

• Joint Moment-A directional force on the joint produce by the GRF. The antagonist muscle groups must work eccentrically to control the joint moment/movement

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Kinetics

• Vertical GRF = Impact

• Anterior-Posterior GRF – Braking Impulse: initial part of stance • eccentric – Propulsive Impulse: latter part of stance • concentric

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Treadmill vs. Overground running

• or running on a treadmill is mechanically equivalent to overground, as long as it is ensured that the treadmill speed does not fluctuate. – van Ingen Schenau GJ. Med Sci Sports Exerc. 1980;12:257-261

• “Treadmill-based analysis of running mechanics can be generalized to overground running mechanics, provided the treadmill surface is sufficiently stiff and belt speed is adequately regulated.” – Riley PO, et al.Med Sci Sports Exerc. 2008;40:1093-1100.

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This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 2 Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Video Analysis Fatigue

• human eye ~ 16 frames/second vs video camera: >60 frames/ • Hip adduction increases during second prolonged run – Dierks et al. JOSPT. 2008; 38: 448-446 • LE mechanics change to increase shock • Capture 3 angles (use tripod): absorption – Kellis E, et al. JOSPT.2009;39:210-220 – Rear --> Coronal plane • Peak leg impacts increase – Side --> Saggital plane – Meardon S et al. CSM poster. 2010 – Front -->Coronal plane / ? • Spinal extensor fatigue changes LE Transverse? muscle activation, trunk and spine kinematics – Hart JM et al. J Electromyograph Kinesiol. 2009;19:458-464 – Hart JM et al. J Athl Train. 2009;44:475-481.

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Mechanics

Loading Alignment

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Shock Absorption

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This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 3 Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Pathomechanics Injury: the Big 6

Rates 20-90% Knee injuries: 42% • PFPS: #1 injury (16%) • Proximal vs Distal Factors: • ITBFS: #2 injury (8%) – In general distal pathologies have distal biomechanical Lower leg//foot: factors and vice versa 36% • Plantar Fascia: #3 injury • MTSS: #4 injury • Achilles: #5 injury

Stress Fx: up to 20% Matheson et al., AJSM 1987 van Mechelen W et al. Sports Med 1992 19 Taunton JE et al. BJSM. 2002;36:95-10120

21 Souza RB, et al. JOSPT. 2009;39:12-19.22

Gait Analysis: Femoral IR

Transverse plane motion: Can not get a perpendicular reference.

So…. – Look at coronal plane to get clues • Rear view: heel whip • Frontal view: dynamic valgus

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This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 4 Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Gait Analysis: Femoral Adduction

Coronal Plane motion.

So… – Look at rear/frontal views • Trendelenburg

• Draw a vertical plumb line from L5/S1, leg/foot should not crossover

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Abnormal Gait Mechanics

• increased hip IR for PFPS – decreased hip abd & ext strength

• increased hip add for ITBFS – decreased hip abd strength

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But what about other areas? Achilles Tendonopathy

Achilles Tendonopathy: Pathomechanics: – 5% of running injuries (Taunton et al 2002) – Decrease knee flexion ROM in 1st half of stance – Forefoot Strike Pattern? – Decreased rectus femoris and gluteus medius activity – Decreased tibialis anterior muscle – Foot type: activation just prior to heelstrike • Pes Cavus or Pes Planus ?!?

Azevedo LB et al. BJSM 2009 29 30

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Achilles Tendonopathy But what about pronation?!?

Pathomechanics: – Increased relative femoral IR during stance Overpronation is defined as excessive – Increased tibial ER throughout stance – Lower tibial ER moment pronation, pronation that occurs too – IR moment of the tibia just after heel strike and just prior to toe-of quickly, or a prolonged duration or pronation during the stance phase.

Williams DSB et al. JOSPT 2008 31 32

But what about pronation?!? Medial Tibial Stress Syndrome

Tibialis posterior is the primary muscle • Poor cushioning responsible for controlling rearfoot • High arches • Out of Shape pronation during loading…if it does not • Training Errors: function properly the medial gastroc Running with fatigue, increased maybe forced to assist in eccentric mileage, control of tibia IR overstriding

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But what about other areas? But what about other areas?

Plantar Fasciosis: Stress Fractures:

– Up to 20% of running injuries (Matheson et al., AJSM 1987) • # 3 Running Injury (Taunton et al. 2002)

– Conflicting evidence on overpronation – Overuse of Passive structures – Increased loading rate – High Impact/Loading – Increased impact

35 36 Pohl MB et al Clin J Sport Med. 2009

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 6 Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Running Injuries Strength (weakness!)

• Injured athletes are likely to have hip abductor, flexor, and external rotator weakness Knee injuries: – Ireland et al. JOSPT. 2003; 33:671-676; – Leetun et al. Med Sci Sports Ex. 2004;36:926-934; 42% of all injuries – Niemuth et al. Clin J Sports Med. 2005; 15: 14-21 • PFPS: #1 injury • Weak hip Abd associated with increased hip (16%) adduction during running (increased with fatigue) in athletes with PFPS • ITBFS: #2 injury – Dierks et al. JOSPT. 2008; 38: 448-446 (8%) • ITBFS sx resolution paralleled the return of hip abd strength – Fredericson et al. Clin J Sports Med. 2000; 10:169-175

Taunton JE et al. BJSM. 2002;36:95-101 37

Abnormal Gait Mechanics Gait (Re)Training

• Goal is to allow runners to train while • increased hip IR for PFPS injured – decreased hip abd & ext strength • Decrease stride length/increase knee flexion at contact – backwards running • increased hip add for – barefoot running ITBFS – uphill running – decreased hip abd strength – cadence manipulation – biofeedback

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Gait (Re)Training: retro running Gait (Re)Training

• Pose Technique • Forefoot strike pattern – midfoot strike pattern – emphasis on shoulder- hip-heel alignment • decreased PFJ contact – emphasis on flexed forces knee throughout gait – Flynn TW et al. JOSPT. 1995 cycle – decreased ground • decreased quad reaction forces eccentric work – decreased knee – Flynn TW et al. JOSPT. 1993 eccentric work

41 Arendse RE et al. Med Sci Exerc Sports. 2004;36:272-27742

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 7 Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Gait (Re)Training: barefoot running Gait (Re)Training: Uphill running

• forefoot strike pattern • midfoot strike pattern

• increased knee flexion @ strike • decreased impact

• increased GMax activity – Chumanov ES. et al Clin Biomech. 2008;23 • increased shock absorption • decreased impact

• decreased braking impulse

Lieberman DE et al. Nature. 2010;463:531-53543 Gottschall JS et al. J Biomech. 2005;38:445-45244

Gait (Re)Training:Biofeedback

• Noehren B, Davis IS. 2010 CSM Poster – n=10 subjects with PFPS and excessive hip adduction during running – 8 sessions of gait retraining with realtime kinematic feedback of their hip adduction curve with a shaded “target area” representing +/- 1 SD of established norms. – subjects were instructed to use their gluteal muscles to keep their curve within the target area – following 8 sessions there was a significant reduction in hip adduction (22 vs 16) and contralateral pelvic drop (-9.4 vs -7.1) and pain (VAS: 5 vs 0.5) all of which were maintained @ 1 month follow-up

45 Crowell HP et al. JOSPT. 2010;40:206-213.46

Gait (Re)Training:Biofeedback

• Willy RW, Davis IS. 2011 CSM Platform – n=10 subjects with PFPS and excessive hip adduction during running – 8 sessions of gait retraining with mirror feedback. – subjects were instructed to “keep your legs apart” and “rotate your knee caps to point forward” – following 8 sessions there was a significant reduction in knee pain and change in mechanics. Mechanical changes were maintained @ 1 month follow-up

Crowell HP et al. JOSPT. 2010;40:206-213.47 48

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 8 Rehabilitation of the Injured Runner 5/21/2011 MNAPTA

Gait (Re)Training Gait (Re)Training: Cadence

• Cadence • 10% Increase – low cadence = overstriding – Increased knee – increased stride length results in greater flexion @ contact COM vertical displacement – increased stride length = greater impact – Decreased peak knee flexion shock – increased cadence = greater use of gluteal – Decreased hip muscles and less on quadriceps adduction (Heiderscheit. Unpublished data. 2010)

49 Heiderscheidt BC et al. 2011 50

Gait (Re)Training: Cadence Gait (Re)Training

• 10% Increase • Conclusion: – Decreased vGRF – Decrease impacts/Braking impulse

– Decreased braking – Discourage heelstrike pattern impulse

– Promote use of gluteals – Decreased impact at Knee & Hip – Decrease painful running

Heiderscheidt BC et al. 2011 51 52

Summary

• Running injuries are associated with abnormal running mechanics

• Physical therapy can help to address abnormal mechanics and muscle imbalances

• Not all runners/injuries are the same

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author. 9