1/15/14. Running Injury Mechanics. Excessive Pronation. Distribution of Running Injuries. 1. Patellofemoral Pain Syndrome

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1 Distribution of Running Injuries Metarsalgia/Stress Fx Running Injury Mechanics Irene S. Davis, PhD, PT, FACSM, FAPTA, FASB Dept. PM&R, Harvard Medical School Director, Spaulding National Running Center FAI/Labral Tears Femoral Neck Fx Hamstring Strains Tibial Stress Syndrome/ Fractures back hip thigh foot lower leg ankle Posterior Tib Tendinitis knee Achilles Tendinitis Patellofemoral Pain Syndrome Iliotibial Band Syndrome Taunton et al, 1 1. Patellofemoral Pain Syndrome Excessive Pronation Most common injury in runners X more common in females 5% of all knee related issues Suggested it may be on a continuum of PFJ OA EV FL Presentation Retro and peripatellar pain associated with knee flexion on a loaded knee Squatting Running Stairs ABD IR Effect of Pronation on the PFJ : A Theoretical Model Apparent Paradox.but if: Prolonged EV Prolonged TIR Eversion = Q Angle Tibial IR As the Knee extends, it needs TER Potential Solution Doesn t explain association of pronation and PFJ Pain Femur IR TFJ ER Q Angle Tiberio, 197 Timing Issue? 1

2 Gender Differences in Movement Gender Differences - Running Single Leg Squat Percent Male Female Valgus Varus Hip ADD Hip IR Knee ABD (val) Foot EV Hip ABD Hip ER Knee ADD (var) Foot INV Hewett, Mechanics of PFPS (females) Mechanics of PFPS (females) 16 1 Isometric Strength (kg) Control PFPS Hip ER Hip ABD PFPS Weaker 6 IR ER -1 Control Knee IR angle (deg) PFPS Inc Knee ER ADD 16 1 ABD PFPS Control Hip ADD angle (deg) Inc. Hip ADD 3 UP DN -3 Pelvic drop angle (deg) Control PFPS Inc pelvic drop Willson et al, Prior studies have been cross-sectional or retrospective A word about males (who also get PFP) 15 PFP 15 CON Healthy male Male with PFPS Female with PFPS Inc. CPD, KADD Inc. CPD, HADD Willy et al, 1

3 But not purely a sex difference Effect of Tibiofemoral Angle on PFJ HADD KADD FEMALES Articular shear, Hydrostatic pressures MALES F-PFP M-PFP Ind. Female Ind. Male HADD 3/1 M-PFP similar to F-PFP /1 F-PFP similar to M-PFP KADD (Varus) 3/1 M-PFP similar to F-PFP /1 F-PFP similar to M-PFP Lat Med Willy et al, 1 15-% demonstrate the opposite sex mechanics Huberti and Hayes, 19, Lee et al., 3, Besier et al., PFPS Associated with High Impacts!. Load rate Impact Peak Impact Loading nd Most common injury in runners Most common injury of the lateral knee X more common in females Presentation Pain at distal lateral knee Often comes on with downhill running Bowser and Davis, 1 Running downhill ITB moves posteriorly Creates friction No diff in Knee Flex (Orchard 1996) Cross-over 3

4 HADD kir Angle (Deg) Retrospective (35 ITBS, 35 con) Knee IR 6 1 % of Stance ITBS Control Angle (Deg) Prospective (17 ITBS, 17 con) Knee IR 6 1 Not RF Eversion! ITBS 1. deg Con -1. deg p=.7 ITBS. deg Con. deg p=. 3. Hamstring Strain Retrospective (35 ITBS, 35 con) Angle (Deg) Hip Add Knee IR 6 1 Prospective (17 ITBS, 17 con) Angle (Deg) Hip Add Knee IR 6 1 Strain of the Hamstring Muscle Mid-substance Insertional -5% in general sporting population ITBS 1. deg Con 7.9deg p=.9 ITBS 1.1 deg Con 1.6 deg p=.1 Hamstring Strain. A crack in the bone from repeated mechanical stress Bone resorption > Bone deposition Overstriding Pelvic Instability 5-3 % of athletes and military recruits Females more likely Tibia most common site

5 Tibial Clinical Presentation Focal Pain with loading Structural Stress Fracture DVT Nerve Entrapment Tumor Low area moments of inertia Long thin bones: lower resistance to bending Tibial Tibial Impact Peak Biomechanical Load rate Tibial Shock Biomechanical High Impact Loading Increased Hip ADD RF EV Free Momwnt Femoral Biomechanical Metatarsal Biomechanical Structural High Arch Low Arch High Impact Loading Low Arch/Eversion High Arch/Inversion Forefoot Striker Excessive stride length Long thin bones Weak feet 5

6 . Increased pressure development in one or more of the four compartments of the lower leg Anterior Lateral Superficial Posterior Deep Posterior Presentation Pain Numbness Weakness lower leg rock hard Elevated Pressures in one of the lower leg compartments due to increased blood flow and/or hypertropy Anterior Lateral Superficial Posterior Deep Posterior 1% of those with unknown lower leg pain Qvarfordt et al, 193 Clinical Presentation Aching, cramping, burning Tightness rock hard Numbness Foot drop Stress Fracture DVT Nerve Entrapment Tumor Stress Fracture DVT Nerve Entrapment Tumor Structural Causes Tight fascia Overtraining Overtraining Overstriding 6

7 Posterior Tibialis Tendinitis Posterior Tibialis Tendinitis Inflammation of the Posterior Tibialis tendon Stage 1 PTTD? Clinical Presentation Pain behind medial malleolus Pain in medial arch Worsens with activity More common in Females More common in flat feet Flex Dig Longus Flex Hall Longus Spring lig sprain Posterior Tibialis Tendinitis Posterior Tibialis Tendinitis Structural Pes planus (limited DF) Excessive EV (RF or MF) Cross-over Gait Toe-out 7

8 Achilles Tendinitis Achilles Tendinitis Inflammation of the Achilles tendon Midsubstance Insertional Presents as am pain and stiffness in tendon % Lifetime incidence -5% Lifetime incidence in runners Forefoot Striker High Arch Low Arch Excessive Eversion Inflammation of the plantar fascia a ligament on the plantar surface of the foot 1% of population will experience Most common cause of heel pain Females X more likely Clinical Presentation Heel pain on first morning step Can extend the length of the PF Loosens up when you run Then begins to get sore at end of run or after Fat Pad Atrophy Tarsal Tunnel Syndrome Calcaneal Stress Fx Flex Dig Brev tendinits Repetitive Traction Injury Structure Limited DF Weak Calf High Arch Low Arch Williams et al, Phh et al,

9 Mechanics Excessive Rearfoot Pronation Excessive Midfoot Pronation Cross-over Toe-out Other factors: Age, BMI, Activity level FAI/Labral Tear group had greater vertical ground reaction force load rates than age and mileage matched controls Pohl et al, 9 Females Pincer Males - Cam HADD and HIR Low Back Pain Pronation Supination Cross-over Anything that causes gait asymmetry High impact loading 9