Running from injury 2

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1 Created as a free resource by Clinical Edge Based on Physio Edge podcast 049 with Dr Rich Willy Get your free trial of online Physio education by clicking here Running injuries & assessment Running assessment Running assessment - should it be performed on the treadmill or overground? Treadmills tend to naturally increase cadence by 4 to 5%, and decrease vertical oscillation. If a runner is an overstrider on the treadmill, they will definitely be overstriking when running on the ground. Otherwise, running patterns will be fairly consistent between running on the treadmill and overground. Gait retraining When performing running retraining, it is important to tailor it to the what you find in your gait assessment, and the musculoskeletal issue the patient is presenting with. For example, if the person has PFJP check if they have excessive step length, hip adduction, slow cadence or increased knee flexion. Increased cadence may decrease hip adduction by a few degrees, which may be of some help with a crossover gait, but you may also need to use an external cue such as using a mirror in front of the treadmill to increase the distance between the knees or keep your kneecaps pointing straight ahead.

2 Patients will adapt the cues to suit themselves, and this is great. Let them know the goal, and allow them to come up with the best solution for them. External cueing, focusing on moving an object rather than focusing on moving themself, is often more effective than internal cues. For example, push the piece of tape on your knee out towards the walls, or focus on the waistband of your shorts, and don t let the waistband dip, keep it level. This improves how automatic the process becomes, and makes the runner more efficient. Provide your runner with ideas for cues, and allow them to adapt the cue or identify the best individual solution to achieve the end result you are after. Running on the treadmill initially is an easier way to start cueing, and the runner can focus on the task rather than having to weave around other people Learning is contextual, and people need to practice their skill in their normal environment. Wearable devices can help the carryover to the outdoors and their normal running environment. Can we change running gait long term? Studies following up 3 months post step-rate/cadence retraining using wearable technology showed sustained increase in cadence. It may not matter if they maintain their new gait pattern long term, as long as they are able to run. Potentially we have shifted their focus away from their painful knee, altered the load on the painful structures while you improved strength, tissue tolerance or changed their training practise so that they can continue running. 2

3 Cadence changes There is a large range of cadence, and the average running cadence is , with a lot of variation on either side. There is not one absolute cadence that everyone should be running at. If you are aiming to increase cadence, have a target 7.5% higher than their current cadence. You don t need to tell the runner HOW to increase their cadence. Show them their current cadence, and tell them you want them to increase that number to your target, allowing them to find their own strategy, which will also evolve over time. If a runner has a higher baseline cadence of 192 or above, don t attempt to increase their cadence any higher. Heel strike There is a lot of variation in foot strike pattern. It is worth asking runners if they have changed their strike pattern, and if so, why? For anterior compartment syndrome, or with tibial stress fractures, foot strike pattern may be important, but how the runner contacts the ground may not be as important in other populations. Faster loading rates from heelstrike are not directly correlated with injury. Combined with this, not all heel strikers have high loading rates, as midfoot landers that land on a flat foot may have very high loading rates as well. Heelstrike needs to occur in front of the centre of mass for running to continue without tripping. Ideally it should be close to the centre of mass with a vertical tibia at footstrike, which may help the knee attenuate forces. Altering or increasing step rate often assists the tibia to be more vertical at footstrike. 3

4 Side view The important aspects to consider when assessing a runner from the side are Capture the hip mechanics from the height of the hip, then lower the camera to capture the foot and ankle mechanics Vertical oscillation - how much does the centre of mass oscillate vertically? There are no valid measures for this, however if it looks excessive it probably is. Measure midstance knee flexion and dorsiflexion. Knee flexion in mid stance - PFJ forces are greatest at mid stance. The typical knee flexion angle at this point is degrees. Faster cadence will often lead to decreased knee flexion angle at mid stance degrees of dorsiflexion is normal for midstance Increased DF will increase the load on the Achilles. Front view May be the least helpful view. ITBS Factors related to ITB pain include increased hip adduction and crossover gait, where the foot crosses over the midline. Contralateral pelvic drop increases peak hip adduction angle and may increase the strain in the ITB. If you are able to reduce pelvic drop and crossover gait, you are likely to reduce ITB strain. If the person has really long strides, and this seems to be increasing their amount of pelvic drop, you can shorten their stride to reduce ITB strain. 4

5 Patellofemoral loads Crossover mechanics and dynamic knee varus is common in male runners with PFJP. You can cue running with a wider running base of support, or run on a track straddling 2 lanes. Is the patient getting PFJP because of increased knee flexion with a large vertical oscillation and long step length? If so, increased cadence by 5 7.5% can be helpful, using a feedback device eg Garmin metronome, iphone app, music If the patient has increased knee flexion at mid stance of >35 40 degrees, increasing cadence will often assist with decreasing this. If cadence changes do not decrease knee flexion, you can ask them to run a little stiffer. Achilles Tendinopathy With achilles tendinopathy, increased and prolonged dorsiflexion may increase the load on the Achilles. Patients that have increased dorsiflexion. There is some data that increased cadence reduces Achilles loads, however this is not seen in Rich s lab. You can ask the patient to stiffen up and run a little stiffer, particularly at the ankle. This tends to decrease Achilles loads and discomfort. You could also try pushing harder into the ground or spring off the ground more. Tibial stress Cadence is one of the main factors. Runners that have high impact forces, sounding like they are hitting the treadmill hard, increasing cadence by 7.5% decreases impact forces by 18 20%. If the runner has trouble increasing their cadence, the sound can be used eg if you can hear your footsteps when you are out running, they can try to quieten their footfall. 5

6 If runners have low impact forces, trying to quieten or soften their landing does not work well, as they may start running like Groucho Marx, crouched over, limiting how much their centre of mass travels vertically, which is also not ideal. Orthotics Off the shelf orthotics, occasionally with quick modifications can be used infrequently where required. Patients that may benefit from short term orthotic use include PFJP patients in the first 6 12 weeks as a short term intervention. Plantar fasciopathy patients can sometimes benefit from an orthotic to decrease their pain in the short term while you are focusing on increasing their strength and tissue tolerance. Metatarsal bars can be used if the patient has metatarsalgia or sesamoiditis. 5th MT stress fractures can be posted to offload the metatarsal head. Use orthotics short term, then orthotics can be discarded. Hallux rigidus patients are one of the few groups that may benefit from longer term orthotics. 6