BIOMECHANICS

A Quick Look at Injuries

Look for these 79 common conditions in runners and joggers.

By Stephen M. Pribut, DPM

ach day millions of injuries are closely related. Americans run. From As your interest and skill in the elite athlete to Figure 1: treating runners grows, contact the casual jogger, local quality running stores runners hit the trails Risk Factors and running clubs and offer Eor the track for fun, sport and talks to the running clubs on health. Running is one of the A variety of contributing factors to running injury prevention. most frequently employed injuries should be noted: forms of vigorous aerobic ex- Approaching Running ercise often used to assist in • Overuse or training errors Injuries (Figure 1) weight control and ease stress. – Inexperience The most frequent cause of It may be helpful for depres- – Terrible Too’s running injuries is thought to sion, lower the risk of metabol- >Too much, too soon, too often, too fast be tissue overload. Historically ic syndrome, lower blood pres- – Intensity termed the “terrible too’s” the sure and lower total cholester- • Miles run per week features are easy to remember: ol, while increasing HDL’s. – Perhaps but may be related to overuse/ Too much, too soon, too often, Running is relatively safe too fast, with too little rest and rapid load increase and usually results in enhanced recovery all too often lead to health. George Sheehan often • Previous running injury injury. Not long ago the “Sud- said that he did not believe that • Incorrect shoe den Runner’s Syndrome” was running would make him live • Flexibility issues seen in which runners had a longer, but would help him live • Strength issues plan to start running tomorrow better and healthier. Running in- • Surface issues and complete a marathon in volves greater forces than walk- • Abnormal biomechanics 6 months. Today many begin ing, swimming or cycling. Treat- HIT or high intensity training ment and prevention of running PhotoDisc Continued on page 80

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Running Injuries (from page 79)

workouts without a gradual increase in load. This can Figure 2: result in a considerable number of injuries. The new athlete needs cautious guidance and should be encour- Exercise Regimen Modification aged to continue their exercise regimen with modifica- tions for gentle adaptation (Figure 2). Relative or absolute rest Contributing to overuse injuries is the overused Strength exercises or mismatched shoe. It is important to examine all Stretching aspects of your patient’s use of running shoes in- Footgear changes (sometimes a return to what has worked) cluding fit, design, age and use including the differ- Form changes ences in training and racing shoes. When you treat experienced runners, they will (including avoiding over-striding) rarely want to hear the advice “stop running”. Save Orthotics that for severe injuries. Keep in mind the concept of Foot to orthotic conformity relative rest. Advise your runners to avoid running to Adequate heel cup depth the point of pain or what would create pain following Frictional characteristics to decrease slipping the run. Review their training schedule and try to de- Load/deformation characteristics termine what activities are possible that will not cause Modern casting technique a rebound increase in pain. Prescribe alternative forms Avoid 2D scanning and foam casting of exercise that may be less stressful such as cycling, Medial skive and inverted technique for rearfoot control pool running, swimming, or the elliptical trainer.

80 Assessment of Problem: History The lower extremity is the area most often injured in offer a portion of the solution to most running-related inju- running, with the knee, Achilles , and foot ries. As we have noted, most running injuries are caused being the most frequently affected structures. Besides the by overtraining and it is important to evaluate where the usual questions regarding time and nature of onset, type training error was made. Correcting overtraining is not of pain and so on, you will need to spend considerable usually sufficient to treat many of the problems seen in clin- time reviewing your patient’s training schedule, other ical practice. It is critical to include assessment of recovery metrics and their training and racing shoes. and where and how load reduction can be achieved. Shoe Biomechanics is only part of the problem and will only changes, running form evaluation, lower extremity strength

Figure 9, A and B: A variety of materials can be used in the fabrication of orthotics for runners. Figure 11: Aged orthotics should be replaced

improvement, core body strength, and stretching to enhance flexibility need to be prescribed as well as a revised training schedule. Sleep, nutrition, and even individual genomics come into play in prevention and treatment of running injuries. Orthotics, of course, do play a role in the treatment and prevention of future running related injuries (Figures 9, 11) but the other parts of the equation must not be neglected.

Training Evaluation and Assessment (Figure 3) Ask your patients to bring in their running logs. These logs should have daily and weekly mileage and brief notes on the run. A variety of devices and apps are useful to record and monitor sleep, nutrition, and mood Figure 10, A and B: The flexion stability test is easily performed. Hold the heel of to help you assess the training load. Feelings of pain the shoe and press it into a flat surface at about 45-60 degrees. The shoe should and discomfort should also be included in the running bend at the ball of the foot (A). If it bends proximal to this point (B), it fails the test. Continued on page 82

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Running Injuries (from page 80) Olympic Marathon. Over the past several years trends have log (Figure 8). You’ll be able to Figure 3: brought us everything from see when an injury began and minimalist shoes to maximal- what training preceded the in- Outline of Training ist shoes. We have seen pro- jury. Look for sudden increas- ponents of forefoot strike and es in mileage. Look for a large Evaluation . Avoid being jump in the long run. Usually in Check for Overtraining swayed by trends. One formula marathon training the long run does not work for everyone. Excessive racing will only increase by one to two Be sure to examine your miles per week. An increase of Running with pain running patient’s shoes. How three or four miles in the long Running while injured or after injury long have the shoes been run and the absence of “easy” Terrain worn and for how many weeks, during which there is a Time of day miles have they been worn? decrease in mileage are red flags. Recovery What is the overall appear- Note the time of day and Sleep ance of the shoe? What is the the type of terrain your pa- Nutrition: Improper diet including inadequate primary feature? Is the main tient has been running on. dietary protein or insufficient caloric intake feature mushy cushioning, A change to running on hills a rocker sole, a forefoot em- may aggravate phasis on design or motion or Achilles tendonitis. Down- control? Has the upper shift- hill running often aggravates ed abnormally? Is the heel peri-patellar pain syndrome. or sole excessively worn? Is 82 Running at night or in dim Figure 4: the wear symmetrical? Do the light conditions may aggra- characteristics of the shoe in- vate mild balance impairment. Shoe-Related Problems crease the risks for the type of A patient recovering from an Excessive shock absorption: injury that the patient has? ankle injury may need to run The aging shoe exhibits Achilles tendinopathy—eccentric in daylight if a proprioceptive more than just a worn sole deficit remains. overload of tendon (Figure 10). The midsole Gait changes that occur Plantar Fasciitis—often too unstable, compresses and loses its with an increase in speed with little flexural and torsional stability shock absorption. The heel work include an increase in Lacing System: may no longer sit perpendic- the number of strides per min- Met-cuneiform exostosis ular to the ground. The upper ute and an increase in stride Dorsal intermediate cutaneous nerve may have holes in it and may length. Over-striding is one compression no longer line up properly of the most frequent training Anterior ankle impingement with the rest of the shoe. flaws and among other dele- Lack of Heel Padding: Haglund’s terious effects this may aggra- Improper Fit: Cross Training vate calf and Achilles tendon The injured athlete needs Subungual hematoma problems, hamstring injuries, to continue exercising in some and increase stress in the ante- Blisters fashion. Encourage and sug- rior tibial muscle group. Too Narrow Width: Neuroma pain gest cross training. You should assist the athlete in setting Physical Examination up their alternative exercise The physical examination will lead you to direct schedule. There is a wide variety of exercises to choose knowledge of what structures are injured. You should from. The specific injury must be taken into account for also perform a thorough biomechanical examination, the decision making process. Some of the possibilities in- evaluate muscle strength and determine which muscle clude cycling, indoor cycling, swimming, elliptical, alterG, groups require stretching or strengthening. and upper body strength training. Recommend exercises When performing a physical examination I follow the that are not likely to delay healing. principles of “Look, Touch, Move.” I start away from the area that I suspect will be most tender and then work towards it. Foot Types This limits responses from the patient anticipating pain. Different foot types have different basic shoe require- ments. The high arched cavus foot presents a higher lat- Shoes eral load to the shoe and will not do well with a spongy It is clear to most that shoes play a role in the cause, the midsole and a motion control shoe. The shape of the last prevention and the treatment of running injuries (Figure 4). should also be matched to the shape of the patient’s foot. Even Abebe Bikila, the barefoot winner of the 1960 Olympic A wide foot will need a shoe wide enough to accommo- Marathon, decided to wear shoes while winning the 1964 Continued on page 84

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Running Injuries (from page 82)

date it. If a patient has avoided injury with a specific Figure 5: shoe model, that should be taken into account when making a shoe recommendation. Shoe type should not Medial Tibial Stress Syndrome be arbitrarily changed and patients should not change shoes because of social pressures. Relative rest Get off of concrete Most Common Injuries Shorten stride The most common running injuries reported are to Lessen medial tibial forces the knee, calf and Achilles tendon, medial tibia, and Decrease bending forces in tibia heel. The specific injuries most often reported include: patello-femoral pain syndrome, calf and Achilles ten- Lessen along posterior tibial tendon don injury, ilio-tibial band syndrome, medial tibial Wobble board for strengthening pain, heel pain and sesamoid injury. Check shoes: stability is often helpful Other notable injuries include stress fractures of Trial of OTC insert the metatarsals, tibia, hip and femur. Custom orthotic to reduce pronatory moments of force Inverted cast technique Tips On Selected Injuries Medial (Kirby) skive

Achilles Tendon & Calf Injuries The calf and Achilles tendon are the most often in- jured in the lower leg region. Your patients with this problem warm-up and gentle stretching after running. In resistant 84 should be advised to avoid hills. They should also avoid cases, some researchers have recommended eccentric shoes that are either too rigid or have excessive cushioning. stretches. Heel lifts are often helpful, and the use of or- Shoes that are too soft exhibit an excessive deformation of thotics should be considered to eliminate tri-planar stress the heel. The calcaneus is moving downwards when it should through the Achilles tendon. be on solid ground. The muscles leading to the Tendo Achil- During the recovery phase the patient should use rel- les reflexively fire to control ankle plantar flexion after foot ative or absolute rest. An elliptical trainer is often helpful. strike. The eccentric contraction causes the muscles to effec- The treadmill should be avoided because the gait alter- tively fire earlier, longer and stronger than usual. ations that occur are not conducive to recovery from this I recommend gentle stretching after a 10-minute easy injury. When returning to outdoor running a shortened stride may help reduce strain in the Achil- les tendon (Figure 6). Figure 6: Medial Tibial Stress Syndrome Achilles Tendon and Calf Until recently, the term “shin splint” was used to refer to many lower leg pains Injury Treatment Outline which included both bone and soft tis- sue injuries. Medial tibial stress syndrome (MTSS) is a more appropriate and specific Relative rest term for what had been called medial shin Cut back mileage splints. It must be distinguished from a Lower intensity tibial using clinical onset Avoid hills, speedwork, plyometrics and location of pain. The pain of MTSS is Consider a bilateral 4-10 mm additional heel lift reported at the medial aspect of the leg, Avoid over-stretching adjacent to the medial aspect of the tibia. Gentle stretch after warm-up Tenderness is usually found between 3 and Start with straight leg calf stretch, build up much later to bent leg. 12 centimeters above the tip of the medial Consider eccentric stretch even later. malleolus at the posterio-medial aspect of Ice Massage—10 to 20 minutes after exercise the tibia. The area of tenderness is more NSAID’s—Aleve, Motrin, etc. 10-14 days. longitudinal in the medial tibial stress syn- drome rather than the often-seen horizontal Check Running Shoes zone of tenderness in a stress fracture. Peri- Replace if heel is worn ostitis may also occur in this location. Replace if excessive heel shock absorption The injured structures usually include (soft air sole cushion, excessive visco-elastic shock absorption) posterior tibial tendon and muscle; how- Replace if shoe is excessively stiff at the “break point” (ball of foot). ever, both the flexor digitorum longus and flexor hallucis longus may also be involved. Continued on page 86

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Running Injuries (from page 84) higher leg (or outside leg) at a greater and joint proprioception. An orthotic risk for this injury (Figure 5). is useful to control eversion forces and A bone scan may be used to assist Your patients should be advised to decrease supination resistance. in the diagnosis. Compartment syn- diminish their training. While running dromes may also occur in this region. on soft surfaces has been recommend- Patello-Femoral Dysfunction/Peri- The primary causes of MTSS are ed for this problem, it is not likely to Patellar Pain Syndrome overtraining combined with forces be helpful. The foot will be less sta- Patello-femoral pain has long been that create tibial bending. The associ- ble and likely have greater tendency a common running problem, but has ated foot type is often found to have for an increase in eversion forces on troubled fewer runners lately. Hip and a high supination resistance or stiff- softer surfaces, such as grass or sand. gluteal weakness is often found in con- ness. Running on a canted surface or Packed dirt would be an ideal surface. junction with the knee pain. Assess the excessive track training will place the I specifically advise against running on biomechanics of your patient, includ- concrete. Shoes with ing limb length and abductor muscle improved stability strength. My usual recommendations Figure 7: features should also include prescribing a decrease in train- be recommended. ing, avoidance of downhill running, a Return to Running Schedule Posterior stretching return to running with run/walk inter- (after injury with four-week layoff) exercises are import- vals (Figure 7), straight leg lifts (10 sets ant. I also recom- of 10 repetitions), bridges to strengthen mend strengthening the gluteal muscles, other gluteal iso- Week Walk/Run Schedule the invertor muscles lating exercises, and, if needed, a sta- 1 Walk 10-20 min. every other day including the pos- bility shoe, and possibly orthotics. PM 2 Walk 20-40 min. 5 days per week terior tibial muscle. 86 3 Jog at easy pace 10 min. + 20 min. walk The wobble board References 4 Jog 15 min. + 20-30 min. walk seems to be an im- Hoffman, M. D., & Krishnan, E. (2014). 5 Alternate for 4-5 Days of week: provement over Health and exercise-related medical issues Run 15 min. / Run 25 min. theraband exercis- among 1,212 ultramarathon runners: base- es since the wobble line findings from the Ultrarunners Lon- 6 Alternate 20 min./30 min. runs gitudinal TRAcking (ULTRA) Study. PLoS board provides a dy- 7 Alternate 20 min./30-35 min. runs One, 9(1), e83867. doi:10.1371/journal. namic exercise and 8 Alternate 25 min./30-40 min. runs pone.0083867 improves muscle Martin, R.L., et al., Achilles Pain, Stiff- strength, balance, ness, and Muscle Power Deficits: Midpor- tion Achilles Tendinopathy Revision 2018. J Orthop Sports Phys Ther, 2018. 48(5): p. A1-A38. Figure 8: Pribut, S. (2010). Overuse injuries of tendon and bone: all the small things. Pribut Pain Staging Podiatry Manag, 157-174. Pribut, S. (2013). The Top Five Run- of Overuse Injuries in Athletes ning Injuries Seen In The Office—Part 1. Podiat Mgt, 187-195 Stage 0: No pain is present before, during or after activity. Minor dis- Pribut, S. (2013). The Top Five Run- comfort may be experienced at various times during training or racing. ning Injuries Seen In The Office—Part 2. Stage 1: Pain or stiffness after activity. The pain is usually gone Podiat Mgt, 181-188. by the next day. Web Resources Stage 2: Mild discomfort before activity that goes away soon AAPSM http://www.aapsm.org/ after exercise is commenced. No pain is present in the latter part of Dr. Pribut’s Running Injuries Site the exercise. Pain returns after the exercise is completed (starting http://www.drpribut.com/sports/sport- within 1 to 12 hours later and lasts up to 24 hours). frame.html Stage 3: Moderate pain is present before sport. Pain is present during sport activity, but is somewhat decreased. The pain is an an- Dr. Pribut is a past pres- ident of the American noyance which may alter the manner in which the sport is performed. Academy of Podiatric Stage 4: Significant pain before, during, and after activity. The . He is a pain may disappear after several weeks of rest. clinical assistant professor Stage 5: Pain before, during, and after activity. The athlete has at the George Washing- stopped his/her sports participation because of the severity of the pain. ton University School of Medicine, and a lecturer The pain does not abate completely even after weeks of inactivity. in the Department of Bio- medical Engineering. He is in private practice in Washington, DC.

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