Common Running Injuries:
Prevention & Rehabilitation
Shana Margolis, MD
Attending Physician, Rehabilitation Institute of
Chicago
Clinical Instructor, Northwestern Feinberg School of
Medicine
Davalyn Partain, PT, DPT
Physical Therapist, Department of Orthopaedic
Surgery, Northwestern Medical Faculty Foundation,
Rehabilitation Institute of Chicago
June 16, 2010
Acknowledgements
Christopher Plastaras, MD
Joseph Ihm, MD
Paul Lento, MD
Jo Fasen, PT, MPT, OCS, CSCS, Cert. MDT
What is Physiatry?
Also called physiatrists
(fizz ee AT’ trists)
Physical Medicine &
Rehabilitation
“Physicians of Function”
4 year residency program
Evaluation and Treatment of
all disabilities
Musculoskeletal and Sports
medicine is one aspect
Musculoskeletal Healthcare
Providers
Physicians
–
–
–
–
–
Diagnose
Order tests
Prescribe Meds
Prescribe therapy
Prescribe
interventions
(injections/surgery)
Types of Physicians:
Physical Medicine &
Rehabilitation
(Physiatrists)
– Non-operative
care of
musculoskeletal
problems
Orthopedic Surgeons
and Podiatrists
– Operate on bones,
tendons, ligaments
Chiropractors
– Specialize in
manual
assessment and
treatment of
musculoskeletal
problems
Physical
Therapists &
Occupational
Therapists
– Specialize in
designing
exercises for
muscle, bone,
nerve problems
Athletic Trainers,
Physical Therapists
Assistants & Aids
– Work closely with
physical therapists to
instruct on proper
exercise technique
Pedorthotist
– Make & advise
orthotic devices,
shoes, braces
Running Coaches,
Personal Trainers,
Pilates/Yoga
Instructors
– Advance
physical fitness
in people
without
pathology or
pain
What is running?
One leg hopping
Leg absorbs force
Requires flexibility
Requires hip girdle
strength
Lengthening
Contraction
– Most damaging to muscle
and requires great
strength
– Fatigue?
Running Injury Prevention
Injury Risk Factors
Extrinsic
factors
– Training errors
– Equipment
Shoe type
Shoe age
– Environment
Surface type
Camber
Direction
Intrinsic factors
– Bone alignment
– Muscle imbalance
– Biomechanical
deficits
Kinetic Chain
Focus
Proximal segments can
influence distal
segment motion
Distal segments can
influence proximal
segment motion
Christopher M. Powers, PT, PhD JOSPT
November 2003 Vol. 33 No. 11 The
Influence of Altered Lower-Extremity
Kinematics on Patellofemoral Joint
Dysfunction: A Theoretical Perspective
Causes of Injury
Trauma (less common)
Overuse
– “Too Much Too Soon Too
Fast”
– Asymmetries
Previous injury
Inflexibility/strength
differences
Terrain (cambered/hills)
Training Errors
too much, too soon, too fast
Increased injury rate beyond 20
miles/week
Inadequate warm-up
Inadequate flexibility and strength
Inadequate rest between runs
Too many miles, too soon
Too much interval/speed training
Running Injuries
Proper diagnosis of injury
Understand goals
Treat underlying cause
Treat kinetic chain
Make sense, be functional
Injury Evaluation
History of
problem
Biomechanical
evaluation
Site-specific
evaluation
Running
assessment
Shoe
assessment
Common Injuries/Problems
Hips/Knees
– Patellofemoral Pain
– Iliotibial Band Pain
– Greater Trochanteric
Bursitis
Feet/Ankles
– Plantar Fasciitis
– Achilles tendonitis
“Shin Splints”
Stress
Reaction/Fractures
Hydration
Hip & Knee Pathology
Patellofemoral Pain
“Runner’s Knee”
Pain located beneath
and/or around knee
cap
Softening and
compression of
cartilage under the
knee cap
>25% incidence in
athletes
Females > Males
Patellofemoral Pain
Vague, achy pain
in front part of
knee
Worse with going
downstairs
Pain when knee
bent for long time
(like in the movie
theatre)
Worse with hills
Patellofemoral Pain
Evaluation
Careful physical examination
Biomechanical evaluation
Running gait evaluation
X-rays usually normal in
mild/early cases
MRI if not getting better
Understanding Function
Abnormal knee cap tracking, abnormal alignment
Knee cap runs on femur “like train on tracks”
Patellofemoral Pain
Causes
Weak hip and core
muscles cause knee
cap to track improperly
Tight quadriceps
Overpronation of the
foot
Rigid foot
Patellofemoral Pain
What do you do when you have it?
Initial Treatment “PRICE”
Protection
Relative Rest (& Gentle
Mobility)
Ice
Compression
Elevation
Patellofemoral Pain
What do you do when you have it?
Training modification
Knee bracing as
prescribed
Patellar mobilization,
manual therapy
Ice regularly
Patellofemoral Pain
What do you do when you have it?
Patellar taping: a
transitional step
– to encourage more force
from quadriceps, help
with pain
Flexibility: ITB, hip
flexors, hamstrings,
quadriceps, calf
– Quadriceps flexibilityemphasis on lower back
position
Patellofemoral
Pain
Additional remedies
known to work!
Chopart strap
Quad and ITB Massage
Change shoes
– get the right type for your
foot
Orthotics
Balance
Iliotibial Band Syndrome
Localized
tenderness on the
outside of the knee
Especially common
when training for
longer distances
~runs over 18
miles
Iliotibial Band Syndrome
ITB passes over outside of femur
bone
Repetitive motion causes rubbing
and inflammation
– Most friction when knee is bent
20-30 degrees
Iliotibial Band Syndrome
Causes
Flat feet with no motion control shoes
High arches with excessive supination
Due to hip girdle weakness and/or
tightness
Leg length difference
Banked terrain, hills & stairs
Increased mileage?
Iliotibial Band Syndrome
What do you do when you have it?
Initial Treatment “RICE”
Relative Rest
Ice
Compression
Elevation
Iliotibial Band Syndrome
What do you do when you have it?
Anti-inflammatories
Soft tissue
mobilization/massage
Foam roll mobilization
Ultrasound
Stretching
Multi-planar
strengthening
Motion control shoes
Shorten stride length
Trochanteric Bursitis
Pain over outer hip
May radiate down
outside of thigh
Back or deeper hip
problem?
Pain laying on side
Increased frequency in
running or contact
sports
Females>Males
Trochanteric Bursitis
Causes
Direct impact or fall
Repetitive friction of
glut med or ITB
Leg length
discrepancy
Hip weakness
Lateral hip surgery
Trochanteric Bursitis
What do you do when you have it?
Initial Treatment
Relative Rest
Ice
Antiinflammatories
Stretching
Trochanteric Bursitis
Treatment: Medical Management
ITB Massage/Mobilization
Ultrasound
Ice/Heat contrast
Multi-planar strengthening
Cortisone shot
Hip & Knee Pathology
Treatment
Thorough Assessment of:
Biomechanical
factors
– Inflexibility
– Strength
– Endurance
– Foot structure
Training errors
Hip & Knee Pathology
Treatment
Gluteal strengthening in
multiple planes
Functional
strengthening, control
“track”
Bracing as needed
Quadriceps
strengthening
Gradual return to
running
Avoid running hills &
stair climbing
Hip & Knee Pathology
Treatment
Strengthening hip & knee stabilizing
muscles in multiple angles
– single leg squats- emphasis knee
mechanics and lumbar spine positionpelvic stability
– stair pelvic drop- emphasis on lumbar
spine position
Gluteal Strengthening
“The Matrix”
Gluteal Strengthening & Balance –
Exercises that Mimic Function
“Power Runner”
Hip & Knee Pathology
Alternate Exercise Options
Cross training with:
Low-resistance cycling
or spinning
Swimming
Pool running
Elliptical
Hip & Knee Pathology
How to prevent its reoccurrence?
Maintain multiplanar
functional gluteal strength –
“The Matrix” in routine
workout 1-2x/week
Preserve flexibility,
especially quadriceps
Slow, progressive return to
activity
Rely on gluteal muscles
more than quadriceps for
stair climbing and squatting
Continue cross-training
Foot & Ankle Pathology
Plantar Fasciitis
Common cause
of heel pain
Pain in the arch
or near heel on
bottom of foot
Worst with 1st
am step
Plantar Fasciitis
Causes
High arched and “flat feet”
Tight plantar fascia
Tight & weak calf muscles
Tight hip flexors
Increase in mileage
Increase in weight
Inadequate shock
absorption of the heel
(shoe wear!)
Plantar Fasciitis
What do you do if you have it?
Ice (water bottle)
Anti-inflammatories
Golf/tennis ball massage
Resting night splint, Ace
wrap
High top shoes or hiking
boots
Orthoses/Heel cups/Taping
Injection
AchillesTendonitis
If Chronic then called
Tendonopathy
Pain in back of heel
Bump present?
Pain with push-off
AchillesTendonitis
Causes
Increased activity level &/or
less recovery time
Overpronation
Tight hamstrings and heel
cords
High arched feet
Weak calves
Frequently wearing high heels
Achilles Tendonitis
What do you do when you have it?
Relative rest
Anti-inflammatories
Ice
Short term
immobilization
(splinting or bracing)
Stretching
Eccentric or Negative
strengthening
Heel lifts
Foot & Ankle Pathology
Treatment
Improve lower limb flexibility,
especially calves
Multi-planar balance exercises
– Single Leg Stance
Static Hold
Dynamic Reaches
Foot & toe strengthening
– Towel Scrunching
Calf Stretching & Strengthening
Calf Stretch & Strengthening
“Stomp the Bug”
“Shin Splints”
(Medial Tibial Stress Syndrome)
Pain located on the
front or inside of shin
Overuse tendonitis of
posterior/anterior
tibialis, soleus muscles
“Shin Splints”
Causes
Overpronation during gait
cycle
Rigid foot
Weak lower leg muscles
Increase of mileage,
speed or new runner
Improper shoe wear
“Shin Splints”
What else could it be?
– Stress reaction of bone
– Stress fracture of tibia bone
– Referred pain from knee
or spine
– Compartment syndrome
“Shin Splints”
Treatment
Relative rest
Crutches if pain is present at rest
or with normal walking
Icing
Stretching
Return to activity gradually (after
pain free period)
– Training should start at 50% of preinjury distance and intensity
– Soft, level surfaces
Orthotics (to correct
overpronation)
Surgery (in resistant cases)
Stress Fractures
Distance
(>20Miles/week)
Usually worse with
activity
– Worse as run progresses
Better with rest
Potential for devastating
injury
Can occur in hip, thigh,
or shin
Stress Fractures
Examination
Bony tenderness
Common areasshins, hips, feet,
thigh, pelvis
X-Rays notoriously
negative
MRI/Bone Scan
better test
Stress Fractures
Treatment
Depends on location
– Likely immobilization or
bracing
Most heal with relative
rest
– cross train/water
running/swim
Some require surgical
intervention
Stress Fractures
Recognize the Symptoms
Pain does not go away during the
run
Hurts every step of the run
Hurts even when walking
Hurts with single leg hop
If you have risk factors: eating
disorder, poor calcium diet, prior
stress fractures, female,
osteoporosis in the family
Running Injuries
WHEN TO SEE THE DOCTOR:
– Simple rest and ice is not
alleviating your pain
– You are unable to train at the
intensity you desire
– You are limited in your day to
day activities because of your
pain
– Joint swelling is your body
telling you something is
wrong; this should be
medically evaluated
– We all get aches and pains
with running, but if your pain
is persistent, this should be
medically evaluated
Fluid Intake
Facts
Water composes 5070% body weight
Typical water intake is
2.4L/day
Requirements vary
depending on temp,
humidity, activity
Water deficits of 5-7%
are assoc w/ dyspnea,
HA, and apathy
Facts
Sweat rate is
approximately 5002000cc/hr in athletes
Athletes typically
consume only half of
fluid losses
Leads to ~3% (2-3lbs)
weight loss in 4 hours
Water Requirements
Lose 2-5% weight
during moderately
intense activityroughly 1.5 L
Typical sweat rates
1L/hr
Theoretically,
dehydration risk factor
for heat illness
Consequences of water
imbalance
If deficit exceeds 2%,
performance
compromised
Increase 1 ºC body
temp for each 1% body
weight loss
Overhydration no
benefit-possibly
detrimental
Electrolytes
Sweat is hypotonic
Sodium generally 1030meq/L
As sweat rate
increases,
concentration of
sodium increases
AND----- with heat
acclimatization sweat
rate increases.
Hence theoretical
increased salt losses
Electrolytes
Salt supplements do
not improve
performance or heat
tolerance
Cramps felt to be
related to electrolytes
but never proven
Currently sodium
supplementation not
recommended-GI
discomfort
Hydration
Sweating rate is
approximately 500-2000cc/hr
in runners
500cc fluid before exercising,
300cc every 20 minutes
evidence to suggest that
consumption of a low
carbohydrate drink during
prolonged and intermittent
exercise will improve
performance (No one type is
superior to the other)
Sport drink comparison
Recommendations
If exercising less than 50 minute, benefits
of drinking questionable
Heat injury may be more related to
intensity of exercise
Recommendations of fluid intake more for
those athletes participating longer than 1
hour
Supplemental salt intake if greater than 4
hours activity
Recommendations
If activity less than 90 minutes, use
water
But 6-8% CHO has been shown to
sustain better power output after 60
minutes, so it may improve
performance particularly if no other
nourishment
Plus sports drinks may taste better
Running Injuries
Conclusion
Proper diagnosis of
injury
Understand goals
Treat underlying
cause
Treat kinetic chain
Be sport specific
Make sense, be
functional
“If I knew that I
was going to live
this long, I would
have taken better
care of myself”
-Mickey Mantle