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1 Running Assessment Workshop Anthony Luke MD, MPH, CAQ (Sport Med) UCSF PCSM Conference 2010 Running boom in the 70 s and 90 s Men then women % of women runners Wheelchair Evolution 26.2 miles km 2:03:59 Haile Gebrselassie (ETH) 3:10 / 3:40 Some numbers 384 marathons in the US #7 of 10 Hardest things to do in sports (USA Today, March 2003) Why did I get an injury? Too much Too hard Too fast for your body!! 1

2 Intake Questionnaire The Ultramarathon Man Biomechanical Analysis 2

3 Station 1 Gait Assessment Excessive forward rotation Pelvis Drop Adequte hip extension Hip Circumduction Station 1 Gait Assessment Knee internal rotation Knee Flexion Knee Extension Ankle dorsiflexion Ankle plantarflexion with toe off Forward lean Stride length Vertical displacement Static posture 3

4 Biomechanics of the Foot and Ankle Foot dorsiflexed, heel inverted Heel strike Heel EVERTS unlocks the midfoot foot adapts to ground Impact greatest from heel strike to midstance Stance Phase (62%) Biomechanics of the Foot and Ankle Mid-Stance or Foot-flat Leg externally rotates and ankle dorsiflexes heel INVERTS locks the midfoot Foot rigid lever Stance Phase (62%) Biomechanics of the Foot and Ankle Plantarflexors propel body forward Toe Off involves the 1 st MTP joint Double float Swing Phase (38%) 4

5 Windlass Mechanism Static Assessment Midstance Toe - off Posture (standing) Lordosis Kyphosis Leg length Genu varum/valgus SLS (30 sec) Posture (standing) Lordosis Kyphosis Leg length Genu varum/valgus SLS (30 sec) 5

6 Posture (standing) Lordosis Kyphosis Leg length Genu varum/valgus SLS (30 sec) Strength Single leg step down Abdominals Hip flexor Gluteus medius Heel raises (20 reps/ea) Quads Hamstrings Glut Max Strength Single leg step down Abdominals Hip flexor Gluteus medius Heel raises (20 reps/ea) Quads Hamstrings Glut Max Strength Single leg step down Abdominals Hip flexor Gluteus medius Heel raises (20 reps/ea) Quads Hamstrings Glut Max 6

7 Achilles Popliteal Angle Quadriceps (prone) ITB (sidelying) Hip Flexor (Thomas) Spine (forward bend, standing) Spine (rotation standing) Gross Ankle mobility: Anterior heel reach Achilles Popliteal Angle Quadriceps (prone) ITB (sidelying) Hip Flexor (Thomas) Spine (forward bend, standing) Spine (rotation standing) Gross Ankle mobility: Anterior heel reach One Leg Squat Hip Abductors 7

8 F l e x i b i l i t y Arch type Thomas Test (Hip Flexor) Ely s Test (Quads) Ober s Test (ITB) Popliteal Angle (Hamstrings) Needed to protect the feet and help maintain biomechanics Heel counter Appropriate cushioning sole Midfoot support Footwear Orthotics Need to consider foot function and foot structure Can help control motion in specific planes Unload sensitive areas Improve efficiency of gait 8

9 Subtalar neutral Material Length (3/4 or full) Lift Posting (forefoot, midfoot, rearfoot) Orthotics Courtesy of Alicia Knee, DPM, UCSF Screening Orthotics Needed to protect the feet and help maintain biomechanics Heel counter Appropriate cushioning sole Midfoot support Footwear Courtesy of Alicia Knee, DPM, UCSF 9

10 Shoe problems Tight shoes bunions, Morton s Neuroma High heels ball of feet Body needs energy Carbohydrates g per hour Gels, bar Nutrition - Fuel Protein gm/kg body weight/day How much to replace? Weigh yourself pre- and post-run Drink more if lose more than 2% body weight Consider heat load Check your urine (light like lemonade OK, dark like apple juice is low) IMMDA suggest ml fluid per hour Answer: Be individual Mechanism Achilles Tendinopathy Repetitive eccentric load on tendon Pushing off, running, sprinting, jumping Presentation Tender over achilles +/- swelling Pain with resisted toe off Pain with passive ankle dorsiflexion 10

11 Risk Factors Khan KM, et al. Phys Sportsmed Tight Achilles and plantar fascia Hyperpronation Cavus foot Advancing age - decreased blood flow Overweight Poor footwear Weak hip abductors and medial quadriceps 3 Basic P/E findings for Tendinopathy 1. Tenderness on direct palpation 2. Reproduction of pain with resisted contraction (eccentric loading) 3. Reproduction of pain with passive stretch Conservative Treatment REDUCE STRESS Modified activities, ice Calf / Achilles stretching Hold each stretch for 30 seconds Soleus stretch Gastrocnemius stretch Heel lifts Modify footwear Custom orthotics Night splints PT is a major key Rarely Surgical debridement Treatment 11

12 Physical Therapy for Achilles Alfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med, 1998; 26:3: RCT eccentric exercises (3 x 15 reps, 2 times/day, 7 days a week x 12 wks) Results: Significant difference in pain levels VAS 81.2 mm (+/- 18) to 4.8 mm (+/- 6.5) in 12 weeks 81% eccentric satisfied vs 38% concentric satisfied Eccentric Drop program Patellofemoral pain Too much pressure under the kneecap The Extensor Mechanism Quadriceps Kneecap Patellar tendon Multifactorial Too tight? Too loose? Patellofemoral Pain Need good muscle balance Quadriceps strength Good flexibility 12

13 Alignment Think Biomechanics Consider orthotics Relative symmetry Control running Worry when running technique alters Patellar tendinopathy Patellar tendinosis Jumper s knee Degenerative changes of the patellar tendon Activity Age Iliotibial band friction syndrome 10-21% of running overuse injuries ITB crosses the lateral femoral epicondyle at 30 Associated with varus moment at the knee Classic history: pain which is reproducible after running a certain amount Painful click laterally Sore especially going down stairs Ober s Test 13

14 ITB Syndrome Fix the underlying problems ITB Stretching Foam roller Hip abductor and medial quadriceps strengthening exercises Correct alignment Modify training Avoid running on cambered road (low side) Avoid downhill Hip External Rotators Hip Abductors Marathon training Train with what you ll compete with Clothes Shoes Fluids Food 14

15 Thank you. 15

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