Rehabilitation of the Injured Runner 5/21/2011 MN APTA US Marathon Finishers Epidemiology of Running 467K Injuries Jason Lunden, PT 25K Board Certified Specialist in Sports Physical Therapy 1976 1980 1990 1995 2000 2005 2009 annual marathon report: runningusa.org Marathon-Lite 2009 Running Data 1200000 Number of Events 1000000 800000 1113K OTHER 600000 Marathon 5 K 5 Mile 400000 Half-Marathon 200000 10 K 303K 0 1990 1995 2000 2005 2009 annual marathon report: runningusa.org annual marathon report: runningusa.org 2010 TCM Age Group Winners Injury: the Big 6 4.5 Rates 20-90% 4 Knee injuries: 42% 3.5 • PFPS: #1 injury (16%) 3 • ITBFS: #2 injury (8%) 2.5 2 Time Lower leg/ankle/foot: 36% 1.5 • Plantar Fascia: #3 injury 1 • MTSS: #4 injury 0.5 • Achilles: #5 injury 0 >80 18-20 22-29 30-34 35-39 40-45 45-49 50-54 55-59 60-64 65-69 70-74 75-79 Stress Fx: up to 20% van Mechelen W et al. Sports Med 1992 Taunton JE et al. BJSM. 2002;36:95-101 2010 TCM Results: mtecresults.com 6 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 MN APTA Injuries in Running Risk Factors Upper Leg Low Back Other Extrinsic (environmental) Intrinsic (person-related) Achilles – Training errors – Previous injury Knee – Running surface – Running experience Hip/Pelvis – Footwear – Flexibility Lower Leg – Strength – Anatomy Foot/Ankle – Gender Tauton JE et. al, BJSM 2002 Risk Factors: Training Errors Risk Factors: Running Surface Too much, too fast! • Asphalt • No evidence for increased risk (Taunton JE 2003, Duffey MJ, 2000) • Crowned Roads • 10% rule • Runners adapt their • Trails mechanics to the running • Shoe replacement surface (Dixon et al. 2000) – 300-500 miles • Hills • Cross training (or lack of!) • Track – always the same – Strengthening direction – Stretching Risk Factors: Footwear Risk Factors: Anatomy • Leg Length Discrepancy: • Runners adapt mechanics to maintain constant GRF/ >5 mm ? (Soukka et al. 1991) Impacts (Kong PW et al BJSM 2009) • Quadriceps Angle: >20°? • Do not reduce injury (Rauh MJ et al. JOSPT 2007) (Knapik JJ et al. AJSM 2010) • Arch Type • Differences in shoe mileage – Pes Cavus b/w injured and controls – Pes Planus (Taunton et al. 2003, Duffey et al. 2000) 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 MN APTA Foot/Arch type Risk Factors: Intrinsic • Experience (Buist I et al 2010, Taunton et No Difference: Increased Risk: al. 2003) • Thijs Y et al. 2008 • Buist I et al. 2010 • Previous Injury (Buist I 2010,Taunton (pes planus for women) JE 2003 Macera MA 1989, Macera MA 1991) • Hreljac et al. 2000 • Flexibility (Hreljac A et al. 2000, Duffey MJ • Van Ginkel A et al. 2009 et al. 2000) (pes cavus for AT) • Taunton JE et al 2002 • Strength (Cichanowski et al. 2007, • Ghani Zadeh Hesar N 2009 Niemuth et al 2005, Duffey, 2000) (pes cavus for any LE injury) • BMI – High for males (Buist I et al 2010, Taunton et al 2002) • Duffey MJ 2000 – Low for females (Taunton et al 2002) (pes cavus for PFPS) Risk Factors: the Evidence Grading Running Injuries Yes! No??? • Grade I: pain after running • Previous Injury • Terrain • Grade II: pain during running, but not • Training • Arch type restricting training (ie discomfort) • BMI • Shoe wear • Grade III: pain during running, which • Weakness • Anatomic alignment • Gender restricts training • Experience • Grade IV: inability to run d/t pain Injuries in Running Anterior Knee Pain Upper Leg Low Back Other Differential Dx: Achilles PFPS Knee Patellar Tendonopathy Hip/Pelvis Meniscal Tear Lower Leg Quadriceps Tendonopathy Fat Pad Impingement Foot/Ankle Stress Fx OCD Lesion Referred pain from hip/back Tauton JE et. al, BJSM 2002 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 MN APTA Anterior Knee Pain Patellofemoral Pain Syndrome Patellofemoral Pain Syndrome(PFPS): 62% of knee injuries #1 Running Injury • Females > > Males • Anterior knee/retropatellar pain • Pain worsens throughout run • Weak Hips: – Abduction (Ireland ML et al, 2003; Cichanowski HR et al, 2007, Souza RB & Powers CM, • Peripatellar pain with palpation 2009) • Patellar mal-tracking: OKC vs – External rotation (Ireland ML et al, 2003) CKC – Extension (Souza RB & Powers CM, 2009) • R/O other pathology • Abnormal Alignment ? (Duffey MJ et al. 2000, Lun V et al. 2003) • Abnormal Mechanics (Duffey MJ et al, 2000, Souza RB et al. 2009, Dierks TA et al, 2011) 19 Patellofemoral Pain Syndrome Lateral Knee Pain Weak Hips + Mal-alignment Differential Dx: ITB Friction Syndrome Mensicus Biceps Femoris Injury Common Peroneal Nerve PFJ Mal-tracking OA Referred pain from hip/ back Peds: SCFE, Perthes’ Asymmetrical Loading 22 ITB Friction Syndrome ITB Friction Test # 2 Running Injury • Pt. Stands on test leg with the knee • 2X increase since 1980 extended • Females > Males • Weak Hips • Examiner applies pressure with their • Abnormal Mechanics thumb against the lateral epicondyle and pulls the knee into slight varus • Terrain Selection: – Crowned roads • Pt. Bends knee to ~45° of flexion – Descending hills – Canted track • Positive: pain @ ~30° KF 23 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 MN APTA Ober’s Test McMurray’s Test • Pt. Is sidelying (test side up) Meniscal Clinical Exam • Medial Mensicus • With knee flexed and hip in neutral – Sens: 57% rotation, extend and adduct the hip – Spec: • Lateral Mensicus • Positive: Hip does not adduct and/or knee – Sens: 77% extends – Spec: Konan S et al. 2009 Thessaly Test “My Knee Hurts” Meniscal Clinical Test • Side of knee ITB Friction • Medial Meniscus Syndrome – Sens: 61-94% • Weak Hips • Over Pronation • Training error: hills, • Lateral Meniscus track, country roads – Sens: 80%-96% Karachalios T et al. 2005 Konan S et al. 2009 Mirzatolooei F et al. 2010 “My Shin Hurts!” Medial Tibial Stress Syndrome Differential Dx: • Pain with palpation of Medial Tibial Stress posteromedial tibial Syndrome (Shin Splints) border Tibial Stress Fx • Pain decreases with warm-up Compartment Syndrome • Pain returns during run Referred pain • Traction perostitis Tumors, Infections etc – Soleus – Flexor digitorum longus 30 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. 5 Rehabilitation of the Injured Runner 5/21/2011 MN APTA Medial Tibial Stress Syndrome “My Calf Hurts” • Poor cushioning Differential Dx: • Over pronation Achilles Tendonosis • High arches Achilles tendon rupture Compartment Syndrome • Out of Shape Stress Fx • Training Errors: Running with fatigue, Popliteal Artery Entrapment increased mileage, overstriding DVT Sever’s disease posterior impingement syndrome Achilles Tendonosis Achilles Tendonosis • Pain to palpation of the Etiology: tendon 2-6 cm superior to • Middle-aged males insertion • Greater BMI • Pain with active plantar flexion • Weak gastroc/ soleus • Pain and limited ROM with • Over pronation passive DF • Tight calves • Palpable thickening and/or crepitus • Training error: increased mileage Achilles Tendonopathy “My Foot Hurts” Physiologic Changes: Differential Dx: – Increased thickness Calcaneal stress fx – Increased compliance Bone bruise of the tendon Fat pad atrophy – Increased tendon- Tarsal Tunnel Syndrome aponeurosis strain Cancer-related pain Paget disease of bone Sever’s Disease S1 radiculopathy 36 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 MN APTA “My Foot Hurts” Plantar Fasciosis • Bottom of Foot/Heel Etiology: Plantar Fasciosis • Tight calves • 8% of running injuries (Tauton et al. 2002) • Over Pronation? • 2 million Americans/year • Decreased 1st MTP (Riddle et al, 2003) mobility • 10% of people (Riddle et al, 2003) • Overweight • Training error: increased • Training error: mileage increased mileage 37 Plantar Fasciosis Windlass Test Examination: • Perform both NWB and – Palpation weight-bearing – Active and Passive • Examiner stabilizes the ROM ankle joint in neutral – Tarsal Tunnel syndrome testing • Examiner extends the st – Windlass test 1 MTP, while allowing the IP to flex – Longitudinal arch angle • Positive: reproduction of pain 39 McPoil TG et al. JOSPT 2008 Tarsal Tunnel Syndrome Test Longitudinal Arch Angle • Pt. Sitting with legs off • Pt. Standing with equal table/plinth weight on both feet • Examiner maximally DF and everts the ankle • Measure the angle of: medial malleolus- and extends the toes navicular tuberosity- • Position is held for 5-10 medial prominence of seconds, While tapping the 1st MTP head over the tarsal tunnel • Positive: increased • Highly predictive of numbness and/or pain dynamic foot posture McPoil TG et al. JOSPT 2008 McPoil TG et al. JOSPT 2008 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 MN APTA “This Stress Fracture is Killing