Treatment of the injured runner:

Evidence for clinical applications

Richard Willy, PhD, PT, OCSAssistant Professor of

Physical TherapyEast Carolina University

Greenville, NC USAwillyr@ecu.edu

Twitter: @rwilly2003

The presenter has no financial relationships or product endorsements to disclose

Outline

1. Epidemiology of running injuries

2. Causes of running injuries: perceived vs. actual

3. Envelope of function

4. Guidelines for treating runners5. How to perform a gait evaluation

6. Classifying running mechanics pertinent to injury

7. Address running mechanics identified as part of etiology

8. Role of shoes9. Therapeutic exercise: economy and for rehabilitation

The new running boomOnly 62% of Americans meet CDC

guidelines www.CDC.gov

Of these, 22% use running to meet levels www.CDC.gov

Upwards of 16 million Americans run at least 3x/week National Sporting Goods Association, 2009

Nearly a 300% increase since 1990 runningusa.org

1990: Female runners 25%

2013: Female runners 57%irunfar.com

Runningusa.org

19.4%-79.3% incidence of running injuries van Gent 2007

Novice runners: inc. >30BMI Nielsen 2014

If obese and novice, highest risk if initiate running with > 3km in the 1st week! Nielsen 2014

Shutterstock.com

Epidemiology of running injuries

Where do runners get injured? Steinacker, 2001 Taunton 2003

Foot14%

Thigh3.4%

Knee50%

Lower leg26.7%

Hip/pelvis9.7%

Ankle11.1%

Patellofemoral pain48.8% of knee injuries

Female: 62% Male: 38%

Often begins in adolescence, continuing into adulthood => PFOA?

Rathleff, 2013, Crossley 2011

Where do runners get injured? Taunton 2002, Callahan 2000, Matheson 1987, Cameron 2013, Lopes 2012

Tibial stress fractures(Tibial stress syndrome)

2.2-7.8%Female: 73.6%

Male: 26.4%6 weeks-9mo loss of running

Bennell and Brukner, 2005

Iliotibial band syndrome1.9-12%

Female: 62% Male: 38%

Leading cause of lateral knee pain

Taunton 2002

Achilles tendinopathy9.1-10.9%Female: 42%

Male: 58%Up to 45% fail treatment

Sayana 2007

PT and runners: the credibility gap

Get to know running

Understand typical training volume

Training errors may or may not be major cause of injuries!!!

Knowledgeable of shoes

Rely on shoe stores for shoe prescription

“Maybe running isn’t for you”

What do runners perceive as causes of running injuries?

Saragiotto 2015

Most frequently cited:

• Not stretching

• Excessive training

• Wearing the wrong running shoes for foot type• Inadequate/unbalanced diet

• Foot type changes

• “not respecting (my) body’s limits”

• Not warming up

RunningInjury

Structure

Mechanics

Physiology, Genetics

Central, psychosocial

Tissue qualities

Training loads

Tissue tolerance,

Ability to adaptBiomechanical

loading

Activity hx, Aerobic fitness Chen 2013, Warden 2014

Bone structure mass/density Beck 2014, Warden 2006

Calf strength, girthClansey 2012, Shindle 2012, Popp 2009

Health, Nutrition, Sleep Tenforde 2013, Lappe 2008

Psychosocial Moran 2013, Stephan 2009

Previous history Tenforde 2013

Load,

Loading cycles Warden 2014,

Taylor and Kuiper 2001

Impact rates Milner 2007, Zadpoor & Nikooyan 2011

Neuromuscular fatigue Milgrom 2007, Fyhrie 1998

Training errors Moran 2013

How to evaluate runnersI. History

A. Injury history: past and present

B. Volume, training breakdown, surfaces

C. Sleep habits, life stressors, emotional responses

D. Diagnostic testing/imaging

E. Stress Fx’s: Bloodwork (Vit. D, Ca++, Thyroid )

F. Type of shoes worn, orthoses

II. Musculoskeletal Screen: preliminary diagnosis

III. Lower quarter assessment

IV. Running assessment

V. Musculoskeletal evaluation

Do non-running factors matter?Sleep-Reduced incidence in stress fractures reduced with enforced

sleep (≥6 hrs) and reducing cumulative marching Finestone and Milgrom 2008

-Adolescent athletes: sleep <8 hours were 1.7x (95% CI: 1.0-3.0)

more likely to sustain injury Milewski 2014

Psychological stressors-Relationship between high perceived stress, unplanned

training volume and stress fracture incidence Moran 2013

-Perceived susceptibility to running injury and overall health threats predictor of prevalence of running injury (r2=0.24, p<0.01) Stephan 2009

Injuries during race preparationIn 12-16 weeks prior to a targeted

race:• Injury: #1 reason nonstarters

(42%) Clough 1987

• 16.3-33% will sustain injury van Poppel 2015, Buist 2008, Mallisoux2014

Novice runners 2.5X more likely to become injured than experienced Videbaek 2015

“…not possible to identify which training errors were related to running related injuries.” Nielsen 2012

Post-Rehab Load CapacityUninjured Load Capacity

Envelope of functionDye 2005

Figures courtesy of Tom Goom, BSc (Hons), MCS www.running-physio.com

Acute: Chronic workload (Gabbett, 2016)Hard training is protective!

Consistent, hard training is protective in runners Rauh 2015, Chen 2013, Warden 2014, etc.

Gabbett 20160.8–1.3

Training time (mins) x sRPE (session RPE rating) = Workload unit (arbitrary unit)

Cumulative loads

Peak loads Rate of loading

Willy and Meira, IJSPT, 2016

Will the real load parameter step forward?Nielsen et al., 2012, Edwards 2012, Miller 2014

Plantar fasciopathyAchilles tendinopathy

Gastrocnemius injuries

Patellofemoral painTibial stress injuries

Degenerative knee issues (OA)

Peak loads

Cumulative loads

Susc

eptib

le to

in

crea

sed

spee

d w

ork

Susceptible to increased running volume

Pathoanatomy or pathomechanics?

Distinctly different mechanics for Iliotibial band

syndrome

Treadmill vs. overground mechanics

Kinematics Fellin et al., 2008, Riley 2007, Willy 2016

Slightly shorter strideTend to land with a flatter foot (less dorsiflexed)Otherwise, very little difference Fellin et al., 2008

Performing 2-D video analysisMinimize perspective errors

Film at the same level as your joint of interest!

Performing 2-D video analysisMinimize perspective errors, cont’d

Key Views

Sagittal view: Whole body1. Trunk position? 2. Hip flexion, extension at toe off?3. Knee angle at footstrike?4. How much knee motion occurs?5. Overstriding? Angle of lower leg?

Sagittal view: Foot1. What is their strike pattern?2. Is there early heel off?

Key Views: cont’d

Rear view: Whole body1. Trunk position? 2. Pelvic drop?3. Hip adduction/medial collapse?4. Hip internal rotation?5. Knee varus thrust?6. Excessive toe out/toe in?7. Is there crossover gait pattern?

Key Views: cont’d

Rear view: Foot and ankle1. Wear does foot hit the ground?2. Is there a pattern of supination to

pronation to re-supination?3. Toe in/toe out?

Front view: Whole 1. How much medial collapse?2. Where is the patella pointing?3. Toe in/toe out?

Common running deviations

Medial Collapse Mechanics

Overstridingmechanics Crossover

mechanics

Injuries associated with medial collapseMostCommonRunningInjuries

%RunningInjuries Female/Male

PatellofemoralPain 22% 62%Iliotibial BandSyndrome 11% 62%

PlantarFasciopathy 10% 46%TibialStressInjuries 7% 57%AchillesTendinopathy 10% 42%

PatellarTendinopathy 10% 43%

Taunton,2002

Medial collapse mechanicsWhat motions are excessive?

What has stress/strain?

a) Patellofemoral jointb) IT Bandc) Tibia and Femurd) Trochanteric bursae) Piriformisf) Medial collateral ligamentg) Femoral acetabular impingementh) Plantar fascia, medial foot

structuresi) Medial kneej) Gluteal tendinopathy

Proximal mechanism in females with PFPContralateral Pelvic Drop

Hip Adduction

Hip Internal Rotation

Knee abduction

Demonstrated in cross-sectional and prospective studies

(Willy et al, 2012, Willson et al., 2007, Souza et al, 2009, Dierks et al, 2008, Noehren et al. 2013)

Axial view of PFJ

Lat Med

Lateral tracking of the patella

Iliotibial Band Syndrome

ITB: Lateral hip and knee stabilizer(Terry 1994, Zenz 2002)

Contralateral pelvic drop and Hip adduction (Noehren 2007, Ferber 2010)

Impingement primarily at the lateral femoral condyle

Primal Illustrations

Medial collapse: Stress fractures Pohl 2008

Tension

Compression

Medial Collapse: Piriformis and g. trochanteric bursitis, gluteal tendinopathy

Kinematics of FAI and Anterior Labral Tear

• Poor control of hip frontal and transverse plane motions during functional or sport activities Austin et al., 2008

• Control of HADD and HIR resulted in >50% reduction in FAI-related pain Austin et al., 2008

Austin et al., 2008

In healthy runners, no correlation with mechanics (Westcott and Willy, 2010)

In PFP, peak strength explains only 3-12% variance in running, jumping, squatting, step descent (Dierks et al., 2007, Willson and Davis, 2008, Souza and Powers, 2009)

Hip strength not predictive of PFP prospectively (Witvrouw et al., 2010, Rathleff 2014)

Hip strengthening does not alter abnormal hip mechanics (Snyder, 2008, Willy and Davis., 2011, Earl, 2011)

“Medial collapse:” What’s the cause?

Souza et al., 2009

Femoral AnteversionOnly with more severe

Souza et al., 2009

Prospective analysis of hip strengthLink not as clear!

Increased hip external rotation strength in PFP Boling 2009

Hip abductor weakness did not predict onset of PFP Boling 2009

Hip strength not predictive in “start to run” Thijs 2011

Hip strength not predictive of medial collapse mechanics Willson 2010, 2011

Prospective PFPNo difference in hip

strength

Hip strength not predictive of medial collapse mechanics

Cross Sectional PFPPFP demonstrate hip

strength deficits

Females with PFP demonstrate medial collapse mechanics

Hip strength deficits a result of PFP!!

Rathleff 2014

Which factors or combination of factors best predict greater hip adduction excursion during running?

MeaningfulpredictorsGMedonsettimeGMedduration

NotmeaningfulpredictorsPelviswidth/femorallengthHipabductionstrength/BWHipERstrength/BWHipExtstrength/BWGMed averageactivationGMax onsettimeGMax durationGMax averageactivation

DelayedandprolongedGMEDactivationpredictincreasedhipadductionexcursion

• P <0.001• R2 =0.45,Adj R2 =0.43• SEE=2.0degrees

Hip adduction prediction: uninjured femalesWillson et al 2009

Medial collapse: SummaryMedial collapse mechanics:

excessive hip adduction, IR, contralateral pelvic drop

Primary pathomechanic in females

Peak strength and alignment play very small role

Motor control of gluteal musculature driving factor

Endurance of gluteal musculature likely important

The effect of a hip strengthening program on mechanics during running and during a single leg squat Willy RW, Davis IS. J Orthop Sports Phys Ther. 2011 Sep;41(9):625-32.

0

2

4

6

8

10

12

14

Hip Abd Hip ER Hip ABD Hip ER

Hip

Tor

que(

%B

W*m

)

Hip Strength PRE POST

Trainers

*

*

Controls

Subjects: 20 Uninjured female “Collapsers”6-week intensive hip strengthening programLast 4 weeks: functional strength training

Willy and Davis, 2011

Results: Running Kinematics

Trainer HADD Trainer HIR Trainer CPD

PRE POST

-5

0

5

10

15

20

25

1 51% Stance

Deg

rees

(+) HADD

-12

-7

-2

3

8

13

18

1 51

% Stance

Deg

rees

(+) HIR

-15

-10

-5

0

5

10

15

1 51Deg

rees % Stance

(-) CPD

Willy and Davis, 2011

Pre-strengthening Post-strengthening

Wouters 2012, Snyder 2010, Bennell 2010

Why is strengthening insufficient to alter abnormal movement patterns?

Strengthening activates different areas of the motor cortex than skill training Jensen 2005

Skill training results in cortical re-organization, strengthening does not Remple 2001

Gait retraining for medial collapseReal time or mirror feedback

Noehren 2011, Willy 2012 & 2013

PRE Training 3 Months

Real time feedback Noehren 2011

Mirror feedback Willy 2012 & 2013

8-sessionsCued: reduction in medial collapse

Age (yrs) km/wk Duration of PFPS (yrs)22.1 ±1.5 23.7 ±11.3 4.3 yrs ±2.5

Results: Demographics and subjective data

Willy et al. 2012

Step 1: train the movement in walking

http://www.yawcam.com/

Software to stream webcam

Markers placed on outside of knees

Cue: “Push marker toward

walls”

Cue: “Push marker toward

walls”

Markers placed on outside of knees

Step 2: Train the movement in runningMedial collapse

BaselineWith video feedback

Cue: “Keep the markers level”

PostBaseline