BIOMECHANICS A Quick Look at Running 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. Too much, too soon, too often, – Perhaps but may be related to overuse/ 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 www.podiatrym.com SEPTEMBER 2018 | PODIATRY MANAGEMENT BIOMECHANICS 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 tendon, tibia 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 SEPTEMBER 2018 | PODIATRY MANAGEMENT www.podiatrym.com BIOMECHANICS 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 barefoot running. 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 plantar fasciitis 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.