2. 2
Disclosures
• I have no relevant financial
relationships with the
manufacturer(s) of any commercial
product(s) and/or provider(s) of
commercial services discussed in this
CME activity
3. 3
Objectives
• Discuss Common Running Injuries
• Identify Possible Risk Factors for Running
Injuries
• Briefly Discuss Evaluation of Various
Running Injuries
• Discuss Treatment of Common Running
Injuries
• Review Possible Preventive Strategies
4. 4
Why Run?
• Increase focus on
healthy lifestyle
• Convenient
• Flexible
• Affordable
• Minimal Equipment
• Individual or Group
Participation
• Health Benefits
• Mental Health
5. 5
Running Injury Incidence
• Annual rates of running
injuries 19.4%-79.3%
• Incidence in those
training for a marathon
is as high as 90%
• Experienced runners are
less frequently injured
• Most injuries are
overuse
6. 6
Running- The Basics
• Gait Cycle
– Begins with heel strike of one foot and ends with heel
strike of the same foot
– Has 2 basic periods, stance 60% and swing 40%
– Stance can be broken into 3 (or 4) phases
• Initial contact, (flat foot), Mid stance, Push/Toe Off
– Swing begins once the foot is no longer in contact with
the ground and has 3 phases
• Acceleration, Mid Swing, Deceleration
7. 7
Running- The Stance Period
Initial Contact Mid Stance Toe- Off
• Foot strike or
impact
• Actively decelerates
the forward-
swinging leg
• Passively absorbs
the shock of the
ground reaction
• Foot makes full
contact
• Body weight shifts
from rear to
forefoot
• Lengthening LE
with concentric
contraction of hip
and knee
extensors
• Push off to
propel runner
forward
8. 8
Running- The Swing Phase
Initial Swing Mid Swing Terminal Swing
• Foot
advances
forward
through the
air
• Foot positions
itself for weight
acceptance
• 3 Foot Strikes:
• Rear, Mid,
Fore Foot
Most injurious the moment is
when the foot collides with the
ground
9. 9
Terminology
GRF at initial
contact
• Ground Reaction Force: forces exerted by the ground on the foot
• Impact forces: when foot comes to sudden stop upon impacting ground
• Concern has been with various foot strike patterns creating higher
collision forces
10. 10
Established Risk Factors
• Extrinsic
– Training
program/errors
– Shoes
– Running surface
– Mileage
• Intrinsic
– Poor flexibility
– Malalignment
– Muscle imbalance
– Previous injury
– Running experience
– Competitive nature
– Age/Sex
3 most common independent risk factors:
- Increase in mileage too quickly
- Previous injury
- Competitive training motive
11. 11
Extrinsic Risk Factors-
Training Program
• Ask about training program
– Specific program, cross training, etc
• Running without a break from training
– Training for more than 1 year
• Less is more?
– Running 1-3 days/week less likely to be injured
• Change in training technique
– 1/3 of those injured had changed training technique or
shoes
12. 12
Extrinsic Risk Factors-
Mileage
• Ask about Mileage
– Longest run, total distance, recent change
• Running distance is considered to be one
of strongest contributors to injury
• Increase in training distance
– Injury rate increases with >20m/wk
– Increase injuries in marathoners
– Longer races associated with LE injuries
13. 13
Extrinsic Risk Factors-
Shoes
• Ask about and evaluate shoes
– Type, how long worn, recent
change
• No studies with sufficient
quality of evidence for “shoe
prescription”
– Many shoes have medial posts or
varus wedges
• Increase supination
• Shoes should be replaced every
300-500 miles
14. 14
Extrinsic Risk Factors-
Surface Type
• No statistical evidence to
link surface type to injury
rates
• Some surfaces have been
linked to certain injuries:
- Harder- PFPS and tibial stress
- Loose surface- meniscal
- Up/down hill- ITB and patellar
tendinopathy
15. 15
Intrinsic Risk Factors-
Previous Injury
• Ask about previous injury
– Where, when, evaluation and rehab
• Previous injury is a significant predictor of
re-injury
– “The timing of recovery is just as important as the
loading of exercise”
– Incomplete healing, uncorrected biomechanical
abnormality, abnormal functioning of repaired
tissue contributes to re-injury
– Studies have shown the injured runners have an
almost 75% increased risk of sustaining another
injury
16. 16
Intrinsic Risk Factors-
Age and Sex and Experience
• Incidence of injury decreased with age and
increases with less experience
• BUT duration of symptoms of injury
increased in older injured runners
• Mean age of 30-40’s for injuries
• Is there selection bias as only injury free
persons continue to run?
18. 18
Intrinsic Risk Factors-
Muscle Imbalance
• Closed kinetic chain theory
– If one joint of lower extremity is not
functioning properly, injuries manifest
in other joints
– Proximal core hip strength needed to
control distal segments
– At foot strike the trunk laterally flexes
towards same side
• Stabilized by balancing contraction of hip
abductors
19. 19
Intrinsic Risk Factors-
Muscle Imbalance
• Hip muscle weakness and overuse injuries
– Injured side
• Weak hip abduction and external rotation
• Hip flexors weaker, hip adductors stronger
• Trend towards hip extensor weakness
• Abdominal muscles control stability of pelvis
– Athletes with injury
• Less core stability
• Lower abdominal performance
20. 20
Location of Injury
• 5 most common
injuries:
– PFPS
– ITBF syndrome
– Plantar fasciitis
– Medial tibial stress
syndrome
– Knee meniscal
injuries
• Most injuries are
overuse rather than
acute
21. 21
Case 1
• 25 year old runner
• Anterior knee pain,
difficult to pinpoint
• Described as achy
• Present with
prolonged sitting
• Can still run but worse
on hills
22. 22
Patellofemoral Pain Syndrome
• Anterior knee pain in/around patella
– PFJ load 5-7x body weight with flexion
• Pathologic origin is not clearly understood and is
not the same for all patients
• Abnormal tracking of patella
– Excessive Q angle
– Deficient vastus medialis obliqus
– Tight vastus lateralis and lateral structures
– Genu Valgum/recurvatum
– Over-Pronation, innominate pelvis, leg length discrepancy
• Irritation of surrounding structures
23. 23
Patellofemoral Pain Syndrome
• Exam
– +/- crepitus
– TTP of medial and lateral patella facets
– Poor Vastus Medialis Obliques (VMO)
– Inflexibility of lateral structures
– + load and grind and inhibition test
– Functional testing
– Poor core, glut, hip strength
• Imaging
– Xray- consider sunrise/merchant view
– MRI- not usually indicated
24. 24
• Treatment:
– Rationale for PT is alleviation of pain by
restoration of patellar alignment
– Reduction of pain/inflammation
• NSAIDs, ice, rest, US
• Improving flexibility of lateral structures
• VMO retraining and strengthening
• Hip, core, glut muscle strengthening
• Patella taping
• Orthotics
– Non op is the mainstay
– One rehab protocol for al PFPS patients does
not exist
Patellofemoral Pain Syndrome
25. 25
Patellofemoral Pain Syndrome
• Gait analysis
– Important in any
runner with injury
– Look at stride,
landing, entire leg
– Needs to be done
by a trained
individual
26. 26
Patellar Tendionpathy
• “Jumper’s knee”
• Degenerative tendinosis
• TTP on exam and also
with functional testing
– Inferior pole of patella or
tendon
– Check for PFPS, abnormal
PFJ biomechanics
• Imaging
– None needed
27. 27
Patellar Tendinopathy
• Treatment:
– Patience!
• First time- 3-6 months to recover
• Long standing - may be 6-12
months
• Eccentric strengthening
– 25 incline board
• US, massage, friction therapy
• Hip, core, glut muscle
strengthening
• Chopat strap
• Referral Sports Medicine if
recalcitrant
28. 28
Case 2
• 55 year old runner
• Lateral knee pain
• Some swelling after
running
• Noticed after doing a
trail ½ marathon
• Feels a clicking at
times
• Has had to decrease
running
29. 29
Meniscal Injuries
• Shear stress with knee flexion
and compression and femoral
rotation
• Twisting mechanism,
degenerative
• May not have immediate
symptoms
• Exam:
– Joint line TTP (knee flexed 45-90°)
– +/- Effusion
– Decreased ROM
– McMurray’s test
– Apply Grind test
– Thessaly test
30. 30
Meniscal Injuries
• Imaging:
– Xray: Can show OA
– MRI: best imaging tool to
diagnose
• Consider if changes treatment
plan or question on clinical exam
• Treatment:
– Conservative initially
• RICE, PT, CS injections, braces
(hinged or unloader), modify
activity
– Surgery if large or
unresponsive to conservative
treatment, or young age
31. 31
ITB Friction Syndrome
• Friction between ITB
and lateral femoral
epicondyle
• During foot strike
• Aggravated by
downhill running or
uneven surface
• Exam:
– + Ober’s & Noble
– Tight TFL and gluteal
muscles but weak
strength
33. 33
Case 3
• 45 year old
overweight female
• Started a running
program to loose
weight
• Having pain in her
heel
• Worse first thing in
the morning
• Told she has a heel
spur in the past
34. 34
Plantar Fasciitis
• Heel or arch pain,
often with first
steps
• Pain at insertion of
the medial
calcaneal
tuberosity
• Heel spur is
incidental finding
on Xray
35. 35
Plantar Fasciitis
• Treatment:
– Rest, NSAIDs
– Stretching
• plantar fascia, gastroc and soleus
• Straussburg sock
– Massage with frozen water bottle
– Supportive shoes with arch at all times
• Silicone heel pad or orthotics
– PT
• Soft tissue therapy, US, strengthening
– Recalcitrant cases: CS inj, ECSWT, Tenex
36. 36
Achilles Tendinopathy
• Pain in either midportion
or insertion
• TTP, thickening, crepitus
• Unilateral calf tightness
• Functional testing
– Heel raises, hop
• Imaging
– Xray- may show
calcification or
enthesophytes
– US can show chronic
inflammatory changse
Musculo-
tendinous jxn
Classic
Midportion
Insertion
37. 37
Achilles Tendinopathy
• Treatment:
– Rest
– Orthotics
– Stretching
– Eccentric
strengthening
– Nitric Oxide donor
therapy
– Soft tissue therapy
on calf and also
tendon
Alfredson’s Eccentric painful heel drop
protocol
- Gastro- knee fully extended
- Soleus- knee flexed to 45
- Both start in demipointe with heel
raised and lower until foot parallel
with ground
- Once no longer pain, increase
intensity
38. 38
Case 4
• 35 year old male
• Has been doing a
lot of 5k races
• Started getting
posterior buttock
and leg pain
• Worse on end of
race with stride
lengthening
39. 39
Hamstring Strain
• More related to explosive ballistic activity
• Very high recurrence rate- 30% +
• Most at the muscle-tendon junction of the
biceps femoris
• Exam
– TTP (check ischial tuberosity), deformity,
flexibility, strength
• Graded based on pain and strength
– 1- pain but strong
– 2- painful and weak
– 3- extremely weak but painless
40. 40
Hamstring Strain
• Imaging:
– Pelvic X-ray
• Treatment:
– Relative to the grade
• RICE
– NSAIDs may blunt normal healing
• Crutches if limp or avulsion
– Referral Sports Medicine
– PT
• Soft tissue and manual therapy, modalities
• Stretching, eccentric strengthening, progression
to activities
41. 41
Case 5
• 18 year old runner
• Training for college
cross country team
• Anterior shin pain on
beginning of run that
dissipates later
• No pain at rest
42. 42
Medial Tibial Stress
Syndrome
• Continuum of “shin splints” or traction
periostitis, stress fracture, frank fracture
• Progression of pain
• 90% involve the posteromedial aspect of
tibia
– Mid to distal 1/3
– High risk is anterior or proximal
• Exam
– TTP, callus formation
– Positive hop test, vibration/tuning fork
43. 43
Medial Tibial Stress Syndrome
• Evaluation/Treatment:
– Tib/Fib Xray is usually negative
– MRI preferred over Bone Scan
– Referral to Sports Medicine
• Rest and activity restriction
– Crutches if pain with walking/ADLs, limp
– Ice
– PT
• Once pain free when walking and no TTP, can
gradually progress, starting with cross training
• Usually takes 2-3 months until full RTP
44. 44
Hip and Pelvis Overuse Injuries
• Gluteal tendinosis
– Pain at the insertion or musculo-
tendon junction and bursa
– Pain with resisted strength testing
• Clam, side lying st leg extension
– PT: eccentric exercises, core
strength
– US guided CS inj
• Greater trochanteric
bursitis
– TTP of the bursa lateral to the
greater trochanter
– Rest, PT with
stretching/strengthening, CS
injection
Gluteus medius bursa
Trochanteric bursa
45. 45
Hip and Pelvis Overuse Injuries
• Piriformis syndrome
– TTP, piriformis stretch, pain
with resisted external rotation
• sciatic nerve passes through in
10%
– PT: stretching external
rotators, core strength,
massage
• SI joint dysfunction
– TTP over SI joint, leg length
discrepancy, trendelenburg
gait, FABER test
– PT with core stability and focus
on abdomino-lumbo-sacro-
pelvis-hip complex
46. 46
Prevention
• Shoes/orthotics/insoles
– No significant reduction in injuries
– Assess need/response with gait analysis
• Stretching
– Insufficient evidence in reduction of injuries
• Graded program
– To minimize risk of injury most recommend not
increasing training by more than 10% per week
• Cross training and strength training
• Barefoot/chi
47. 47
Conclusion
• Running is a very popular economical
sport
• Multifactorial etiology of running
related injuries
• The history is extremely important in
diagnosis
• Difficult for runners of all levels to
follow the advice to “stop running”
49. 49
References
1. van Gent RN, Siam D, van Middelkoop M, et al. Incidence and determinants
of lower extremity running injuries in long distance runners: a systematic
review. Br J Sports Med 2007;41:469-480.
2. Yeung EW, Yeung SS. A systematic review of interventions to prevent lower
limb soft tissue running injuries. Br J Sports Med 2001;35:383-389.
3. Johnston CAM, Taunton JE, Lloyd-Smith DR, McKenzie DC. Preventing
running injuries: practical approach for family doctors. Can Fam Physician
2003;49:1101-1109.
4. Taunton JE, Ryan MB, Clement DB, et al. A prospective study of running
injuries: the Vancouver Run “In Training” clinics. Br J Sports Med
2003;37239-244.
5. Taunton JE, Ryan MB, Clement DB, et al. A retrospective case-control
analysis of 2002 running injuries. Br J Sports Med 2002;36:95-101.
6. Jacobs S, Berson B. Injuries to runners: a study of entrants to a 10,000
meter race. Am J Sports Med 1986;14;151-155.
7. Buist I, Bredewg W, Lemmink K, et al. Predictors of running-related injuries
in novice runners enrolled in a systematic training program. Am J Sports
Med 2010;38: 273-280
50. 50
References
8. Marti B, Vader JP, Minder C, Abelin T. On the epidemiology of running
injuries: the 1984 Bern Grand-Prix study. Am J Sports Med 1988;16:285-
294.
9. Niemuth P, Johnson R, Myers M, Thieman T. Hip muscle weakness and
overuse injuries in recreational runners. Clin J Sport Med 2005;15:14-21.
10. Leetun D, Ireland M, Willson J, et al. Core stability measures as risk
factors for lower extremity injury in athletes. Med Sci Sports Exerc
2004;36:926-934.
11. Rolf C. Overuse injuries of the lower extremity in runners. Scan J Med Sci
Sports 1995;5:181-190.
12. Fields K, Sykes J, Walker K, Jackson J. Prevention of running injuries. Curr
Sports Med 2010;9:176-182.
13. Hreljac A. Impact and overuse injuries in runners. Med Sci Sports Exerc
2004;36:845-849.
14. Ferber R, Hreljac A, Kendall K. Suspected mechanisms in the cause of
overuse running injuries: a clinical review. Sports Health 2009;1: 242-246.
15. Fredericson M, Misra A. Epidemiology and aetiology of marathon running
injuries. Sports Med 2007;37:437-439
51. 51
References
16. Robbins S, Hanna A. Running-related injury prevention through barefoot
adaptations. Med Sci Sports Exerc 1987;19:148-156.
17. Hoeberigs J. Factors related to the incidence of running injuries. Sports
Med 1992;13:408-422.
18. Hreljac A, Marshall R, Hume P. Evaluation of lower extermity overuse
injury potential in runners. Med Sci Sports Exerc 2000;32:1635-1641.
19. Sato K, Mokha M. Does core strength training influence running kinetics,
lower extremity stability, and 5000-m performance in runners? J Strength
Cond Research 2009;23;133-140.
20. Brill P, Macera C. The influence of running patterns on running injuries.
Sports Med 1995;20:365-368.
21. http://barefootrunning.fas.harvard.edu/index.html
22. Lieberman DE, Venkadesan M, Werberl WA et al. Foot strike patterns and
collision forces in habitually barefoot versus shod runners. Nature
2010;463:531-535.
23. Brukner Peter and Karim Khan. Clinical Sports Medicine (3rd). Australia:
McGraw-Hill Australia, 2009.
