Keys to the Office Based Evaluation of the Youth Runner

Transcription

1 Keys to the Office Based Evaluation of the Youth Runner Michelle Cappello, PT, SCS Clinical Director of Physical Therapy and Athletic Training Sports Medicine Center for Young Athletes UCSF Benioff Children s Hospitals 12/15/2018

2 Disclosure The CME Committee reviewed the commercial interest and nature of the financial relationship that was disclosed and determined there was no relevant financial relationship with a commercial interest

3 Learning Outcomes Describe basic biomechanical demands required for running Describe normal interaction of the hip, knee, ankle, and foot during functional movements specific to the run cycle. Describe clinical exams for range of motion, stability, and functional tasks related to running. Plan appropriate treatment interventions based on clinical exam findings.

4 Cardiovascular fitness (e.g. running ability), but not muscle strength, is strongly associated with higher cognitive performances. Fact For Thought Aberg MA, Pedersen NL, Torén K, et al. Cardiovascular fitness is associated with cognition in young adulthood. Proc Natl Acad Sci U S A Dec 8;106(49):

5 A study of 1.44 million people shows being physical active (e.g. running) is associated with an average 20% lower risk of 13 types of cancer. Fact For Thought Moore SC, et al. Leisure-time physical activity and risk of 26 types of cancer in 1.44 million adults. JAMA Internal Medicine. May 16, 2016.

6 Running Basics Humans were born to run! Running is a common denominator in youth sports Sports participation requires running, but fails to train how to run 80% of running related injury related to overuse (material fatigue) Van der Worp et al, 2015, PLOS Avoiding fatigue is easy Run really slow Land really close to your body Land really soft Downside = nowhere quickly 6 Keys to Office Exam of the Youth Runner

7 Material Fatigue Demands > Durability

8 Tissue Overuse & Injury: Envelope of Function 8 Dye, Clin Orthop Rel Res, 1996

9 Most common sites of injury in runners 1. Knee (42%) 2. Foot/ankle (17%) 3. Lower leg (13%) 4. Hip/pelvis (11%) 5. Achilles/calf (7%) 6. Upper leg (5%) 7. Low back (3%) 8. Other (2%) 10 most common overuse injuries in runners 1. Patellofemoral pain (21%) 2. ITB friction syndrome (11%) 3. Plantar fasciitis (10%) 4. Meniscal injuries (6%) 5. Shin splints (6%) 6. Patellar tendinitis (6%) 7. Achilles tendinitis(6%) 8. Gluteus Medius injuries (4%) 9. Tibia stress fractures (4%) 10. Spine injuries (3%) 9 Taunton et al., Br. J Sports Med, 2002

10 Office Based Evaluation of the Youth Runner Physical Assessment Posture Range of Motion Stability / Control Balance Strength / Power Motion Analysis Synthesis of Information Plan of Action Najee Davis: UCSF BCHO Athlete of the Month April 2013

11 Start with History Where is pain What causes pain Any previous injury How often do you run Miles per week Recent changes; surface, shoes, volumes, overlapping seasons Other exercises Goals most patients don t want to run slow; Performance over injury prevention if they want speed, they need to earn it. 11

12 Physical Assessment Physical Assessment evaluates functional movement patterns specific to the components of running Shock Absorption Balance Propulsion / Power Evaluate the functional pattern then break it down - MOBILITY = enough range for optimal biomechanical patterns - STABILITY = true dynamic stability to not collapse under load - STRENGTH = power to propel body up against gravity Special Tests as necessary based on symptoms and limitations 12

13 Physical Assessment: Functional Testing Posture Neutral Runners should hip hinge degrees = Forward Trunk Lean, less PF Stress Straight line from cervical spine to sacrum Teng & Powers JOSPT

14 Physical Assessment: Functional Testing Posture Poor Trunk Control in Sitting Poor postural endurance -> flexed runner Decreased lumbar lordosis / posterior pelvic tilt Increased thoracic kyphosis Deactivates gluteals Increased demand on quads Decreased hip hinge

15 Physical Assessment: Functional Testing Posture Head and Trunk Control in Sitting Upright runner

16 Physical Assessment: Functional Testing Posture Postural Test for Core Control Prolonged sitting can put undue stress and pressure on a child s musculoskeletal system & forms bad habits Triggering: Postural endurance limits shortening of the hip and knee flexor muscles Correct with Crown to Ceiling a few times/hour

17 Physical Assessment: Functional Testing Posture Overhead Reach Test with Core Control Indication of upright trunk and postural control Runner places back and head flat against wall Try to touch thumbs overhead keeping elbows straight & back flat against wall Evaluate in standing, then in supine to check PROM vs. AROM, x 10 reps. Limitations due to UE mobility deficit Thoracic spine stiff into extension Spinal stability dysfunction Scapular stability dysfunction 17

18 Physical Assessment: Functional Testing Posture Linking UE & LE

19 Physical Assessment: MOBILITY Range of Motion Needed for Running Hip Extension 10 minimum Hip: achieve both passive and active hip extension or will increase demands at the knee and ankle Knee: at contact loading 0 Propulsion push off Full flexion for mid-swing (speed) Foot/Ankle: DF 10 with knee extended 30 with knee flexed Big Toe Extension = Presentation Title

20 Physical Assessment: STABILITY Stability of Core: Planks Front AND Side Planks Should be able to maintain full hip extension and abduction Test each side for symmetry 30 seconds is the goal for holds Important for trunk posture during stance limb to control shock / impact 20

21 Physical Assessment: STABILITY Core

22 Physical Assessment: STABILILTY Functional Testing Single Limb Balance Assess total body load acceptance Keeps the body in proper postural alignment Minimum of 10 seconds Elite = >25 seconds Limb Symmetry Index of >90% is desired * Trunk lean compensation * Hip drop dysfunction 22 Presentation Title

23 Physical Assessment: STABILITY Functional Testing Single Limb Squat Assess shock absorption pattern Specificity of braking, stability, and propulsion for muscle actions Mimics unilateral stance phase of running gait pattern, abductor strength and control (Earl 2007) 65 degrees is reviewed as normal achievement with good mechanics and no pain (Kivlan 2012) Running requires control of degrees of knee flexion for impact stability 23 Presentation Title

24 Physical Assessment: STABILITY Functional Testing Single Limb Squat Poor Single leg squat associated with posterior chain weakness which is underdeveloped in pre/adolescents (Wilk PMR 2016) Patterns are weak, note quality of squat PFPS individuals have greater ipsilateral trunk lean, contralateral pelvic drop, and knee abduction (Nakagawa 2012) Limb Symmetry Index of >90% is desired with Y Balance Anterior Reach Test Measure distance other leg can reach forward from toe of stance leg 24 Presentation Title

25 Physical Assessment: STABILITY Functional Testing Single Limb Squat Highlights dynamic tracking of Hip/pelvis in the frontal and rotational planes 3-5 practice reps Goal for running 3 x 20 if can do well 25

26 Physical Assessment: STRENGTH Choose the right target areas Hip strategy! For acceleration (Pandy 2010), runners need gluteus maximus, gluteus medius, vasti, soleus, and gastrocs Bilateral Squat Dynamic valgus /symmetry =poor movement strategy Early heel rise? =*tight heel chords Knee forward quad dominant strategy leads to over stride. Hips back = good glut recruitment, contact close to COM. 26

27 Physical Assessment: STRENGTH

28 Physical Assessment: STRENGTH Strength / Control Gluteals Full hip extension allows for power with propulsion hip drive from initial stance mid stance Functional Leg lift test Functional Bridge Hip Drive Should be able to maintain full hip extension Minimum of 15 reps Photo credit to C.Deprato UCSF PT 28

29 Physical Assessment: STRENGTH Bridge Test Double leg, then try single leg for 15 repetitions Essential for stance limb stability & propulsion Should be able to maintain full hip extension Preserve stable spine Positive test = default to hamstrings, hamstring cramp, contralateral pelvis drops 29

30 Physical Assessment: STRENGTH Runner s Calf Raise Double leg to get full height of heel lift, then test is singles Essential for stance propulsion Should be able to perform 20 single heel lifts at full height Foot to remain facing forward, no toe in or toe out bias Positive test = lack of full height, foot turn out, excessive pronation on way down. 30

31 Physical Assessment: Functional Testing POWER Strength: Propulsion Power Broad Jump (Double leg) Distance should be own height Single leg Broad Jump = >90% Look for LSI >90% R vs. L 31

32 Physical Assessment: Functional Testing Motion Analysis Running Depending on symptoms, Goal is to see how they run Objectively measures what body is doing Look for inefficiencies and injury inducing mechanics 32

33 Physical Assessment: Functional Testing Motion Analysis Running Video Analysis on phone or office ipad check posterior view pelvic drop knee window (no knocked knees) check anterior view medial knee collapse in stance leg trunk side lean in/towards stance leg check side view Trunk lean 10 & postural alignment hip extension 10 Can they get their leg behind them Landing close to their body 33

34 Keys to the Office Based Evaluation of the Youth Runner Posture Exam holds neutral spine with arms overhead x10 Mobility Hip extension >10 degrees Mobility Great toe extension >30 degrees Stability Plank holds front/side 30 seconds Stability Single Leg balance 30 seconds Stability Single Leg Squat x 10 with good mechanics Strength Double Leg Squat with good hip strategy x 10 Strength Bridge Test double & single leg Strength Runner s Lean Single leg calf raise x 20 each side Power - Broad Jump (double leg) distance = patient s height Power - Broad Hop (single leg) 70-90% of height Walking Test: 10 minutes at fastest speed (just short of jogging). No pain or limping. Step and Hold: 20 small leap steps from the one limb to the other limb. Step should be at least the distance of the patient s normal stride length with gait.

35 Keys to Office Exam of the Youth Runner Review of Findings List Physical Assessment & Run analysis findings: Establish a Plan of Care Mobility deficits = stretch & mobilize target areas Stability deficits control and coordination in patterns Strength/power isolate weak muscles, then build power with patterns of movement Mechanics gait retraining with movement rehabilitation specialist Neither will focus more on shoes, volumes/demands, and medical considerations 35

36 Thank You! Michelle Cappello, PT, SCS Clinical Director Sports Medicine Center for Young Athletes