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Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runner’s Clinic at UVA Team Physician, Ragged Mountain Racing Common Running Injuries
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Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Mar 29, 2015

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Page 1: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Robert P. Wilder, MD, FACSMChair, Physical Medicine & Rehabilitation

The University of VirginiaMedical Director, The Runner’s Clinic at UVA

Team Physician, Ragged Mountain Racing

Common Running Injuries

Page 2: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Objectives

• Identify common contributors to running injuries

• Describe treatment for heel pain, stress fractures, and patellofemoral pain syndrome

• Understand the importance of proper mechanics in managing injury

• Outline criteria for running while treating injury

Page 3: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Epidemiology of Running Injuries

30 million active runners70% all runners sustain significant injury

40% knee15% each: shin, achilles, hip/groin10% foot and ankle5% spine

25% recreational5% elite

Page 4: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Epidemiology of Running Injuries

4% bit by dogs0.3% hit by bicycles0.6% hit by cars7% hit by thrown objects

Page 5: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Principle of Transition“Culprits & Victims”

Page 6: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Intrinsic Abnormalities

MalalignmentMuscle imbalanceInflexibilityMuscle weaknessInstability

Page 7: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Extrinsic Abnormalities

Training errorsEquipmentEnvironmentTechniqueSport-imposed deficiencies

Page 8: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Examination of the Injured Runner

HistoryBiomechanical assessmentSite-specific examDynamic examShoe examAncillary testing

radiologicelectrodiagnosticcompartment testing

Page 9: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

History• Prior injury history• Team/Club• Identify transitions• MPW (20, 40)• Long run (< 1/3 weekly total)• Intensity• Surface (? Muscle tuning)• Shoes/orthotics (350-400 miles)• Cross Training• Goals• Life Stressors/fatigue• Females: eat d/o, menstrual irreg, osteopenia

Page 10: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Physical Examination

• Biomechanical assessment• Site specific examination• Dynamic examination• Ancillary testing• Shoe examination

Page 11: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

• Single Leg Stance• Single Leg Squat• Bilateral Squat• FHB isolation• Step-down Test• STAR Excursion Test• Swing Test

Page 12: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

Single Leg Stance

Page 13: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

Single Leg Squat

Page 14: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

Bilateral Leg Squat

Page 15: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

FHB Isolation

Page 16: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

Step-Down Test

Page 17: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

STAR Excursion Test

Page 18: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functional Screening

Swing Test

Page 19: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,
Page 20: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain in Runners

Page 21: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Plantar Fasciitis• 10% U.S. Population• 600,000 outpatient visits annually• 7-9% all running injuries

Page 22: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Plantar Fascia• Thick aponeurosis• Arises from medial

calcaneal tuberosity• Spans arch• Bands circle flexor

tendons• Insert proximal

phalanx

Page 23: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Functions During Gait Cycle• Heel strike: Allows midfoot to become flexible,

absorb shock, conform to uneven surface• Toe off: Windlass Mechanism: Shortening

increases arch, locks midtarsal, stabilizes toe off

Page 24: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Pathophysiology

• Overuse• Inflammation• Chronic changes (collagen necrosis,

angiofibroplastic hyperplasia, chondroid metaplasia, matrix calcification)

• Tearing• Medial vulnerable (thin, limited vascular

supply, limited ability to stretch

Page 25: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Risk Factors• Obesity• Excessive time on feet• Limited ankle motion (tibiotalar)• Limited great toe mobility (extension)• Inflexibility (HS and achilles)• Pes cavus• Pes planus• Leg length inequality (short leg)

Page 26: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Presentation• Plantar heel pain• A.M. pain• Mid arch (sprinters)• Increased pain with

running• Imaging primarily to rule

out other causes

Page 27: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Treatment

• Relative Activity Modification• Anti-inflammatories• Flexibility (HS, gastroc-soleus, plantar fascia)• Manual therapy (ankle and great toe mobility:

tibiotalar subtalar, great toe)• Strength (Foot intrinsics, ankle stability, lower

quarter stability)

Page 28: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Treatment (cont)

• Devices – CTF brace, heel cushions• Low dye taping• Night splints and socks• Inserts• Steroid injections

Page 29: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Treatment (cont)

• ESWT (> 12 mos)• Botulinum A• Autologous blood• PRP• Prolotherapy

Page 30: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Recalcitrant Cases

• Confirm diagnosis• Surgical release– 75-95% “some improvement”– 27% significant pain– 20% activity restriction

• Fasciectomy + neurolysis of nerve to ADM• Percutaneous plantar fasciotomy• Flouroscopically-assisted fasciotomy• US guided fasciotomy

Page 31: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential

• Fat Pad Insufficiency• Calcaneal Stress Fracture

Page 32: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Neuropathies– Tarsal Tunnel Syndrome– Medial plantar nerve

(“Joggers Foot”)– First Branch, Lateral

Plantar nerve (“Baxter’s Neuropathy”)

– Radiculopathy

Page 33: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Tendonopathies– PTTD (posterior tibial)– Flexor– Peroneal– Achilles

Page 34: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Spring Ligament injury

Page 35: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Bursitis– Pre-achilles– Retrocalcaneal

Page 36: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• OS Trigonum Syndrome (differentiate from posterior talus fracture)

Page 37: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Haglund’s

Page 38: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Sever’s Syndrome (kids)

Page 39: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Achilles enthesopathy (consider inflammatory)

Page 40: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Differential (cont)

• Tarsal coalition

Page 41: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Heel Pain Considerations

• Ankle mobility (tibiotalar, subtalar great toe)• Flexibility (HS, GS, PF)• Ankle stability• Lower quarter stability

Page 42: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,
Page 43: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Stress FracturesFailure of bone to adapt adequately to mechanical loads (ground reaction forces and muscle contraction) experienced during physical activity

1. Tibia2. Metatarsals3. Fibula4. Navicular

Page 44: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Stress Fractures - Pathophysiology

Page 45: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Stress Fractures (cont)

• Non-critical (relative rest 6-8 wks)• Medial tibia• Metatarsals 2,3,4

Page 46: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Stress Fractures (cont)

At risk fractures:– Femoral neck– Anterior tibia– Medial malleolus– Navicular– Base 5th metatarsal

Page 47: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Femoral Neck

Superior (distraction) – higher incidence worsening/ non union

Inferior – (compression)

Page 48: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Anterior Tibia

Casting vs relative rest up to 6-8 months

If no healing – ortho (transverse drilling, grafting, medullary fixation)

Page 49: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Navicular• Tender N-spot• Critical zone middle 1/3• Non-weight bearing 6-8

weeks• Progressive activity

over 6 more weeks

Page 50: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Proximal 5th Metatarsal

• Jones fx of proximal diaphysis• Cast 6-10 weeks• Non-union: ortho• Consider ortho early in

competitive• Contrast with avulsion:

symptomatic RX

Page 51: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,
Page 52: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Patellofemoral Syndrome• Pain associated with the

articular surface of the patella and femoral condyles, its alignment and motion

• “Runners Knee” #1 presenting complaint to Runner’s Clinics

• #1 cause lost time in basic training military recruits

Page 53: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

PFS - Classification

• Patellofemoral instability• PFS with malalignment• PFS without malalignment

Page 54: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

PFS – Contributing Factors

• Bony abnormalities• Malalignment • Soft tissue abnormalities

Page 55: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

PFS – Bony Abnormalities

• Dysplasia of femur

• Asymetry of patellar facets

Page 56: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

PFS – Lower Extremity Malalignment

• Femoral anteversion• Increased Q angle• Knee valgus (knock kneed)• Lateral patellar tilt• Lateral tibial tuberosity• Abnormal tibial torsion• Hyperpronation• Restricted dorsiflexion

Page 57: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

PFS – Muscle/Soft Tissue Imbalances

• Weak, delayed activation VMO• Weak quads• Tightness Quads, ITB, hamstring, gastroc• Weak hip muscles , abductors, gluts

Page 58: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Patellofemoral Syndrome - Diagnosis

• Anterior, peripatellar, subpatellar pain• Downhill and downstairs• Theater sign• Contributing factors• Apprehension (shrug) sign• X-ray

Page 59: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Patellofemoral Syndrome - Treatment

• Correct the functional deficits!• Bracing, taping• Foam roller• Correct pronation (if excessive)• Adjust training – avoid hills, bike mod• Correct the functional deficits!

Page 60: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,
Page 61: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,
Page 62: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Shoes

• Lots of options (a good thing)• Can affect impact forces, loading rates, torque forces• ? Relation to shoes, form or both• Rarely does “one size fit all”• If it ain’t broke, don’t fix it?• All transitions gradual• With barefoot, minimalist ensure stability and form

cues

Page 63: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,
Page 64: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

• Cross train (aqua run, eliptical bike)• Walk, then walk – jog, then run• 10% per week rule• Long run increases no more than 2 miles

Page 65: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Relative Activity Modification Guidelines

Rule #1

• If you feel mild pain (0-3/10): it is OK to run• If you feel moderate pain (4-6/10): reduce activity

until pain level is mild.• Severe pain (> 7/10): no running

Page 66: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Relative Activity Modification Guidelines

Rule #2

• Pain that decreases with activity is OK.• Pain that gets worse with activity is bad; time

to reduce or stop activity.

Page 67: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

Relative Activity Modification Guidelines

Rule #3

• No limping allowed.• If the pain alters your gait pattern, it is time to

reduce or stop the activity until you have normal biomechanics.

Page 68: Robert P. Wilder, MD, FACSM Chair, Physical Medicine & Rehabilitation The University of Virginia Medical Director, The Runners Clinic at UVA Team Physician,

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