Running Injuries

Bill Wiley

ORV

July 24, 2003

Introduction

• Approximately 30 million Americans run for recreation or competition (Novachek 1998)

• Running is Not for Everyone (certain body types are contraindicated)

• Pre-existing conditions cause many injuries• Some should be directed to other activities• Runners are tough and usually exhaust self-help

remedies

Classification/Levels

• Lutter Clin Sp Med 1985– Level 1 (Jogger/Recreational) - <10 miles/wk– Level 2 (Sports Runner) – 10 to 30 miles/wk– Level 3 (Long Distance) – 30 to 60 miles/wk– Level 4 (Elite Marathoner) – 60 to 180 miles/wk

Gait Cycle

• Definition: Period from initial contact of one foot until the contact of that same foot.

• 2 Phases:– Stance Phase – foot is touching ground– Swing Phase – foot is not touching ground

Gait Cycle

Gait Cycle

• Percentage of Stance Phase– Standing 100%– Walking 60%– Running 31%– Sprinting 22%

Kinematics

• Pelvis, Femur and Tibia IR during early Stance Phase (heel strike)– Eversion and Unlocking of the subtalar joint

which allows a more supple foot for shock absorption

• At Toe-Off there is ER of pelvis, femur and tibia – Inversion and Locking of subtalar joint which

makes it more rigid for energy transfer

Kinematics

• Differences btwn Running and Walking– ROM increases as velocity increases– Body lowers center of gravity w/increased

speed– Walking Heel contacts the ground first– Running usually contact posterolateral foot– Running has a double float phase (Swing)– Walking has a double support phase (Stance)

Kinetics

• Vertical Ground Reaction Force– Walking 1.3 to 1.5 times body weight– Running 3 to 4 times body weight

• During running the forces are occuring at least twice as fast, therefore the increased strain on the skeletal and soft tissues is not 2, but a 4-fold increase

Kinetics

• Assuming a stride length of 4.5 feet, a runner will take 1,175 steps per mile.

• Therefore a Marathon runner could take over 30,000 steps

• If impact is 250% of body weight and weigh 150 lbs then the runner absorbs 110 tons on each foot per mile (220,000 lbs)

Beach’s 6 S’s of Running

• Structure (a predisposing body type)

• Shoes (Worn out or improper type)

• Surface (Uneven, hard)

• Strength (weak muscles)

• Stretching (not allowing enough warmup)

• Sudden Change (increased too fast or even

not giving body enough rest)

Specific Problems

• Overuse

• Stress Fractures

• Exertional Compartment Syndrome

• Specific Injuries– Sprained Ankle– Torn Meniscus

Overuse

• Iliac Crest Apophysitis• Iliotibial Band

Syndrome• Patellofemoral

Syndrome• Patellar Tendonitis• Shin Splints

• Achilles Tendonitis• Posterior Tibial

Tendonitis• Peroneal Tendomitis• Plantar Fasciitis• Turf Toe

Patellofemoral Syndrome

• Most Common Knee Problem• Mechanical features that predispose

– Femoral Anteversion– Valgus Knees– Pronated foot

• Other Risk Factors– Weak Quads– Tight Hamstrings– Overweight– Female

Patellofemoral Syndrome

• Treat by strengthening quads

• Stretching Hamstrings

• Ice

• NSAIDs

• Possibly Orthotics

Iliotibial Band Friction Syndrome

• Runners Knee

• Most common problem on lateral side of knee

• Initiated by a long run and aggravated by running downhill or on a slant

Iliotibial Band Friction Syndrome

• Pathology is the IT band rubbing over the Lateral femoral condyle

• Abductor Fatique and Weakness contribute as well as prolonged varus stress

Iliotibial Band Friction Syndrome

• Exam findings are tenderness over the distal ITB and LFC

Iliotibial Band Friction Syndrome

• Treatment– Ice – NSAID’s– Capsaicin cream and friction message– Stretching– Activity modification– Rarely surgical release of the posterior 2 cm of

the ITB

Stress Fractures

• Pars Interarticularis

• SI joint

• Pelvis

• Femoral Neck

• Tibia

• Fibula

• Metatarsal

Stress Fractures

• Frequency by location (Renstrom ICL 1993)– Tibia 34%– Fibula 24%– Metatarsals 18%– Femur 14%– Pelvis 6%– Others 4%

Stress Fractures

• Can Take 2 to 4 weeks before the xray is positive

• Bone Scan and MRI for earlier detection

• Bone Scan may remain hot for 14 to 24 months so be careful in using as a tool to RTS

Femoral Neck Stress Fractures

• Pain and achiness in groin, anterior thigh or knee• Often an antalgic gait• 4 to 10x’s more common in females (Jones 1989)• 2 types (Devas JBJS 1965)

– Compression (more common in young pts)• Inferior part of neck

– Distraction (more common in older pts)• Superior part/Tension side of neck

Femoral Neck Stress Fractures

Femoral Neck Stress Fractures

• Treatment– Any displacement Fix– Nondisplaced Compression, NWB w/crutches

and rest until pain-free (4 – 6 wks)– Distraction type – tx w/Internal Fixation

acutely

Jones Fracture

• 75% of chronic fractures occur in patients between 15 and 21 yoa and most are male.

• Cavus Foot is more likely b/c increased loads on outside edge and is a more rigid foot

Jones Fracture

Blood Supply is poor to the base of the Fifth MT (Shereff et al Foot Ankle 1991)

Treated with 4.5 mm cannulated Herbert Whipple Screw

Exertional Compartment Syndrome

• History– Pain, achiness or tightness after activity– Relieved with rest– May have numbness, paraesthesia or weakness– Most commonly affects the anterior

compartment but has been described in all 4– 75 to 90% have Bilateral symptoms

CECS

• Physical Exam– Often no abnormality is found– 20 to 60% have a muscle hernia (13% normal

have this as well)• Occurs in the distal anterior compartment where

the superficial peroneal nerve exits the fascia

– May have tightness or fullness if exercised soon before exam

• 15 yo WF c/o Left leg pain while training for basketball. Pain for 8 months

• Xrays negative

EJ

EJ

Rest 5 min 15 min

Ant 21 23 --

Lat 22 42 30

DP 11 12 --

SP 9 8 --

CECS

• Testing– Xrays and Bone Scan to R/O Stress Fractures– Compartment Pressure Monitoring (Pedowitz

AJSM 1990)• Pre-exercise > 15 mmHg

• 1 minute Post > 30 mmHg

• 5 minute Post > 20 mmHg

Leversedge AJSM 2002 – superficial peroneal nerve pierces fascia 13.5 cm (range of 8 – 17.5 cm) from tip of distal fibula

EJ

• One week later patient underwent Anterior and lateral compartment release by way of 2 incision technique

• Patient is back to training with no pain

Chronic Ankle Instability

• Mechanical Instability– Anterior Translation

• Over 10 mm on one side or over 3 mm side to side difference

– Talar Tilt• Over 9 degrees on one side or more than 3 degrees

side to side difference

Chronic Ankle Instability

• Functional Instability– A subjective feeling of the ankle giving way

during physical activity or during simple everyday activities after a sprain

Chronic Ankle Instability

• Treatment Options– Therapy will help a significant portion– Direct Repair (Brostrum)– Tenodesis (Chrisman-Snook, Watson-Jones)– Ligament Reconstruction

DB

• 25 yo WF with chronic ankle sprains and catching and locking in her Right ankle

DB

• The patient was taken to the OR for diagnostic ankle arthroscopy

• The leg was placed in an arthroscopic leg holder with the tourniquet as high up and the leg brought down as far as possible

• Nothing was seen from the anterior portals, but there was significant synovitis

DB

• A posterolateral portal was made and the probe identified a large loose body which was removed with a grasper.

Ankle Impingement

• Bony Impingement– “Soccer Players Ankle”

• Osteophytes on the anterior rim of the tibia where the soft tissues get trapped between the tibia and talus during dorsiflexion

• Felt to be due to a traction injury to the capsule when the foot is repeatedly forced into extreme plantar flexion

Ankle Impingement

• Bony Impingement– Usually develops over a period of 10 yrs or

more– Occurs in soccer, dancing, running, basketball

Ankle Impingement

• Bony Impingement– May have swelling and tenderness anteriorly– Pain with dorsiflexion– Exostosis on lateral xrays– Forced Dorsiflexion lateral may show

osteophytes or a divot sign (divot in the anterior talus allowing the osteophyte room to engage)

Ankle Impingement

• Bony Impingement– Treatment is ankle arthroscopy and

excision of the osteophyte

Ankle Impingement

• Soft-Tissue Impingement– Meniscoid Lesion (Ferkel Lesion – AJSM

1991)• Persistent Anterolateral Ankle pain after an

inversion injury and sprain

• Hypertrophied synovium or a torn end of the ATFL becomes entrapped on dorsiflexion

Ankle Impingement

• Soft-Tissue Impingement– Typically no evidence of instability on exam– Pain with Dorsiflexion– Pain in the anterolateral border of the ankle– Relief of symptoms with injection

Ankle Impingement

• Soft-Tissue Impingement– Treatment is ankle arthroscopy and resection of

the lesion