Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Rehabilitation of the Injured Runner: Addressing Running Mechanics

Jason B. Lunden, PT Board Certified Specialist in Sports Physical Therapy

Excel Physical Therapy Bozeman, MT

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Rehabilitation of the Injured Runner

•  Education •  Pain relieving modalities •  Taping/bracing/orthotics •  Manual Therapy •  Strengthening •  Neuromuscular control •  Gait Training

Objectives •  Review the basic biomechanics of running

•  Describe examples of pathomechanics associated with running injuries

•  Demonstrate how physical therapists address the pathomechanics of running and the treatment of the injured runner

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Phases of the gait cycle

Measures of the Running Gait Cycle

•  Stride Length: the distance between foot contact points of the same foot

•  Step Length: the distance between foot contact points between feet

•  Cadence: the number of steps per minute

Phases of Running Gait Cycle •  Impact: up to 3x BW

•  first 50% of stance phase = greatest eccentric load

•  3 main strike patterns: –  Heel –  Midfoot –  Forefoot

Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Biomechanics Review •  GRF-the force of the ground on the

foot

•  Joint Moment-A directional force on the joint produce by the GRF. The antagonist muscle groups must work eccentrically to control the joint moment/movement

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Kinetics •  Vertical GRF = Impact

•  Anterior-Posterior GRF –  Braking Impulse: initial

part of stance •  eccentric

–  Propulsive Impulse: latter part of stance

•  concentric

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Treadmill vs. Overground running

•  Walking or running on a treadmill is mechanically equivalent to overground, as long as it is ensured that the treadmill speed does not fluctuate.

–  van Ingen Schenau GJ. Med Sci Sports Exerc. 1980;12:257-261

•  “Treadmill-based analysis of running mechanics can be generalized to overground running mechanics, provided the treadmill surface is sufficiently stiff and belt speed is adequately regulated.”

–  Riley PO, et al.Med Sci Sports Exerc. 2008;40:1093-1100.

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Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Video Analysis •  human eye ~ 16 frames/second

vs video camera: >60 frames/second

•  Capture 3 angles (use tripod): –  Rear --> Coronal plane –  Side --> Saggital plane –  Front -->Coronal plane / ?

Transverse?

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Fatigue

•  Hip adduction increases during prolonged run

–  Dierks et al. JOSPT. 2008; 38: 448-446

•  LE mechanics change to increase shock absorption

–  Kellis E, et al. JOSPT.2009;39:210-220

•  Peak leg impacts increase –  Meardon S et al. CSM poster. 2010

•  Spinal extensor fatigue changes LE muscle activation, trunk and spine kinematics

–  Hart JM et al. J Electromyograph Kinesiol. 2009;19:458-464

–  Hart JM et al. J Athl Train. 2009;44:475-481.

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Mechanics

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Loading Alignment

Shock Absorption

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Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Pathomechanics

•  Proximal vs Distal Factors: –  In general distal pathologies

have distal biomechanical factors and vice versa

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Injury: the Big 6 Rates 20-90%

Knee injuries: 42% •  PFPS: #1 injury (16%) •  ITBFS: #2 injury (8%)

Lower leg/ankle/foot: 36%

•  Plantar Fascia: #3 injury

•  MTSS: #4 injury •  Achilles: #5 injury

Stress Fx: up to 20% Matheson et al., AJSM 1987

van Mechelen W et al. Sports Med 1992 Taunton JE et al. BJSM. 2002;36:95-101

21 22 Souza RB, et al. JOSPT. 2009;39:12-19.

Gait Analysis: Femoral IR Transverse plane motion: Can not get a

perpendicular reference.

So…. – Look at coronal plane to get clues

•  Rear view: heel whip •  Frontal view: dynamic valgus

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Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Gait Analysis: Femoral Adduction

Coronal Plane motion.

So… – Look at rear/frontal views

•  Trendelenburg •  Draw a vertical plumb line from L5/S1, leg/foot

should not crossover

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Abnormal Gait Mechanics

•  increased hip IR for PFPS –  decreased hip abd & ext strength

•  increased hip add for ITBFS

–  decreased hip abd strength

But what about other areas? Achilles Tendonopathy:

– 5% of running injuries (Taunton et al 2002)

– Forefoot Strike Pattern?

– Foot type: •  Pes Cavus or Pes Planus ?!?

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Achilles Tendonopathy Pathomechanics:

– Decrease knee flexion ROM in 1st half of stance

– Decreased rectus femoris and gluteus medius activity

– Decreased tibialis anterior muscle activation just prior to heelstrike

30 Azevedo LB et al. BJSM 2009

Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Achilles Tendonopathy Pathomechanics:

–  Increased relative femoral IR during stance –  Increased tibial ER throughout stance – Lower tibial ER moment –  IR moment of the tibia just after heel

strike and just prior to toe-off

31 Williams DSB et al. JOSPT 2008

But what about pronation?!?

Overpronation is defined as excessive

pronation, pronation that occurs too

quickly, or a prolonged duration or

pronation during the stance phase.

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But what about pronation?!? Tibialis posterior is the primary muscle responsible for controlling rearfoot pronation during loading…if it does not function properly the medial gastroc maybe forced to assist in eccentric control of tibia IR

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Medial Tibial Stress Syndrome •  Poor cushioning •  High arches •  Out of Shape •  Training Errors:

Running with fatigue, increased mileage, overstriding

But what about other areas?

Plantar Fasciosis: •  # 3 Running Injury (Taunton et al. 2002)

– Conflicting evidence on overpronation

–  Increased loading rate

–  Increased impact

35 Pohl MB et al Clin J Sport Med. 2009

But what about other areas? Stress Fractures:

– Up to 20% of running injuries (Matheson et al., AJSM 1987)

– Overuse of Passive structures

– High Impact/Loading

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Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Running Injuries

Knee injuries: 42% of all injuries

•  PFPS: #1 injury (16%)

•  ITBFS: #2 injury (8%)

Taunton JE et al. BJSM. 2002;36:95-101

Strength (weakness!) •  Injured athletes are likely to have hip abductor,

flexor, and external rotator weakness –  Ireland et al. JOSPT. 2003; 33:671-676; –  Leetun et al. Med Sci Sports Ex. 2004;36:926-934; –  Niemuth et al. Clin J Sports Med. 2005; 15: 14-21

•  Weak hip Abd associated with increased hip adduction during running (increased with fatigue) in athletes with PFPS

–  Dierks et al. JOSPT. 2008; 38: 448-446

•  ITBFS sx resolution paralleled the return of hip abd strength

–  Fredericson et al. Clin J Sports Med. 2000; 10:169-175

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Abnormal Gait Mechanics

•  increased hip IR for PFPS –  decreased hip abd & ext strength

•  increased hip add for ITBFS

–  decreased hip abd strength

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Gait (Re)Training •  Goal is to allow runners to train while

injured •  Decrease stride length/increase knee

flexion at contact – backwards running – barefoot running – uphill running – cadence manipulation – biofeedback

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Gait (Re)Training: retro running

•  Forefoot strike pattern

•  decreased PFJ contact forces

–  Flynn TW et al. JOSPT. 1995

•  decreased quad eccentric work

–  Flynn TW et al. JOSPT. 1993

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Gait (Re)Training •  Pose Technique

–  midfoot strike pattern –  emphasis on shoulder-

hip-heel alignment –  emphasis on flexed

knee throughout gait cycle

–  decreased ground reaction forces

–  decreased knee eccentric work

Arendse RE et al. Med Sci Exerc Sports. 2004;36:272-277

Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Gait (Re)Training: barefoot running

•  forefoot strike pattern

•  decreased impact

•  increased shock absorption

Lieberman DE et al. Nature. 2010;463:531-535 44

Gait (Re)Training: Uphill running •  midfoot strike pattern

•  increased knee flexion @ strike

•  increased GMax activity –  Chumanov ES. et al Clin Biomech. 2008;23

•  decreased impact

•  decreased braking impulse

Gottschall JS et al. J Biomech. 2005;38:445-452

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Gait (Re)Training:Biofeedback •  Noehren B, Davis IS. 2010 CSM Poster

–  n=10 subjects with PFPS and excessive hip adduction during running

–  8 sessions of gait retraining with realtime kinematic feedback of their hip adduction curve with a shaded

“target area” representing +/- 1 SD of established norms.

–  subjects were instructed to use their gluteal muscles to keep their curve within the target area

–  following 8 sessions there was a significant reduction in hip adduction (22 vs 16) and contralateral pelvic drop (-9.4 vs -7.1) and pain (VAS: 5 vs 0.5) all of which were maintained @ 1 month follow-up

46 Crowell HP et al. JOSPT. 2010;40:206-213.

47 Crowell HP et al. JOSPT. 2010;40:206-213. 48

Gait (Re)Training:Biofeedback •  Willy RW, Davis IS. 2011 CSM Platform

–  n=10 subjects with PFPS and excessive hip adduction during running

–  8 sessions of gait retraining with mirror feedback.

–  subjects were instructed to “keep your legs apart” and “rotate your knee caps to point forward”

–  following 8 sessions there was a significant reduction in knee pain and change in mechanics. Mechanical changes were maintained @ 1 month follow-up

Rehabilitation of the Injured Runner MNAPTA

5/21/2011

This Information is the property of Jason Lunden, PT, SCS and should not be copied or otherwise used without express written permission of the author.

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Gait (Re)Training •  Cadence

–  low cadence = overstriding –  increased stride length results in greater

COM vertical displacement –  increased stride length = greater impact

shock –  increased cadence = greater use of gluteal

muscles and less on quadriceps (Heiderscheit. Unpublished data. 2010)

Gait (Re)Training: Cadence

•  10% Increase –  Increased knee

flexion @ contact

–  Decreased peak knee flexion

–  Decreased hip adduction

50 Heiderscheidt BC et al. 2011

Gait (Re)Training: Cadence

•  10% Increase –  Decreased vGRF

–  Decreased braking impulse

–  Decreased impact at Knee & Hip

51 Heiderscheidt BC et al. 2011 52

Gait (Re)Training •  Conclusion:

– Decrease impacts/Braking impulse

– Discourage heelstrike pattern

–  Promote use of gluteals

– Decrease painful running

Summary •  Running injuries are

associated with abnormal running mechanics

•  Physical therapy can help to address abnormal mechanics and muscle imbalances

•  Not all runners/injuries are the same