Evaluation and Treatment of the Injured Runner: A Movement System Approach

Transcription

1 Evaluation and of the Injured Runner: A Movement System Approach Ryan DeGeeter, PT, DPT, SCS, CSCS Washington University Program in Physical Therapy St. Louis, MO Judy Gelber, PT, DPT, OCS, CSCS Children s Hospital of Omaha Omaha, NE Gregory Holtzman PT, DPT, SCS Washington University Program in Physical Therapy St. Louis, MO Disclosures: No relevant financial disclosures exist for any of the presenters 1

2 General Principles for the Evaluation and of the Injured Runner Testing principles: Movement Impairment: A pattern of movement resulting from repeated movements (i.e. running) or sustained postures performed throughout the day that is associated with pain or injury when the cumulative physical stress on the body region is of a sufficient amplitude, frequency or duration. Adaptations of muscle strength, length, and recruitment all contribute to the movement impairment demonstrated. Source versus Cause: The source is the tissue or anatomical structure that is symptomatic while the cause is the mechanical factor (movement pattern) that results in tissue or structural irritation. Runners typically focus on the source of pain, while physical therapists have the expertise to link the source of symptoms to a cause. Secondary testing: A verbal, tactile or manual cue used to change the movement impairment. When secondary testing reduces symptoms, the suspected movement impairment is confirmed. Secondary testing should occur in conjunction with any tested movement that causes pain, including walking and running analyses. Principles for modification of running mechanics: Trial period: Choose 3-5 strategies that target the desired running mechanics modifications. It is often necessary to try 2-3 different verbal cues that aim at the same running mechanics change (i.e. increase, land more quietly, lean forward all cause similar changes). Instruct the patient to try only one strategy each run and note feasibility as well as effect on symptoms during and after the run. Multiple strategies may be effective, but during the trial period only one should be used per run. The goal is to find one or more pain-reducing strategies that do not require excessive attention from the runner. Interval training: Interval training: ly used during the trial period (above) and again when employing final strategies. Train at a set ratio of run to walk time. Often, a patient changing his/her stride is only able to maintain the "corrected" technique for short periods (commonly 1-3 minutes). Most patients quickly revert back to preferred running techniques, especially in the absence of frequent feedback and encouragement to maintain the "corrected" technique. Ratio of intervals can be modified based on acuity of injury, cardiovascular fitness, or simply by the patients ability to independently maintain the corrections. Combining running strategies with external support: External support, such as taping, bracing, orthotics and footwear, can be employed in conjunction with running modifications. If symptoms are not acute, consider adding external modifications as one of the strategies employed during the trial period (only one strategy allowed per run). This allows the patient to weigh for him/herself the effectiveness of each strategy. If symptoms are acute or patient is weak, consider using both external support and running modifications, and weaning from support as the patient progresses through PT. 2

3 Key Narrow foot placement or crossover Contralateral hip drop and/or prolonged medial femoral Narrow knee window Movement Pattern: Hip adduction/medial Femoral Rotation Frontal and/or Transverse Plane impairments of the Hip Region Often associated with the inability to adequately accept loads associated with running or compensations to accommodate physical loading. Rear foot strike pattern Slow / increased step length / long stance time movement into ankle/foot pronation Involvement Greater Trochanteric Bursa ITB Patellofemoral medius Lateral hamstring Key Tests of Movement Quality Partial squat: Double leg first. as able stance Strength / Deep hip lateral rotators gluteus medius Length TFL-ITB Hip adductors Medial hamstrings Hip lateral Rotators (long) Structural Femoral anteversion Genu valgum options Wider foot placement (slight) Increase (5-10%) /decrease step length Incline training Anterior trunk lean Options Home exercise MMT positions used to isolate weak muscles: Deep hip lateral rotators (90 degrees of hip flexion), med., max. Functional strengthening in weight-bearing: stance/ squat, lunge, sidestepping Taping to prevent femoral medial Cross training (out of sagittal plane) Daily activities standing posture and sleeping exercises indicated: TFL- ITB 3

4 Key or rapid hip with knee from foot strike through push-off Movement Pattern: Hamstring Impairment: Hip Extension with Knee Extension Sagittal plane impairment of the hip/knee (hamstrings) Primarily associated with overuse of the hamstring muscle during the stance phase of running gait. Key Tests of Movement Structural options Options Home Involvement Quality Strength / Length exercise distance from foot strike to Center of Mass Insufficient hip flexion during swing femoral medial Tibial lateral during swing Hamstring(s) Inferior patellofemoral Prone hip with knee Step-up stance and single leg squat (as able) gluteus medius Deep hip lateral rotators Hamstring(s) /Soleus Hamstrings /Soleus Femoral anteversion or retroversion Swayback posture (not necessarily structural) Improve push-off with gluteals Increase (if needed) Heel lift MMT positions to isolate weak muscles: Deep hip lateral rotators (90 degrees of hip flexion), med, max, Hamstrings Functional strengthening in weight-bearing: stance, step-ups Daily activities: standing posture and stairs Hamstring Taping Eccentric hamstring training exercises: Hamstrings & /soleus 4

5 Key knee flexion during the initial portion of swing phase Movement Pattern:Hamstring Impairment: Knee Flexion with Insufficient Hip Flexion Sagittal plane impairment of hip/knee Primarily associated with overuse of the hamstring muscle during the initial swing phase of running gait. Observable during initial swing. with backside mechanics knee during stance Involvement Hamstring(s) Hip flexors Key Tests of Movement Quality Prone hip with knee stance as able Jogging in place Strength / Hip flexors (group) / soleus gluteus medius Length Hamstrings /Soleus Hip flexors Structural Swayback posture (not necessarily structural) options Improve hip drive with swing Incline running Options Home exercise MMT positions are used to isolate weak muscles: Hip flexors, med, max, Functional strengthening in weight-bearing: stance (focus on nonstance limb) Jogging in place with appropriate cues for hip flexion Daily activities to address: standing posture and stairs exercises as indicated: Hamstrings and /soleus 5

6 Key Poor or painful eccentric control of knee during terminal swing Movement Pattern: Frontside Hamstring Movement Impairment Sagittal plane impairment of the hip/knee Primarily associated with pain in and/or poor recruitment of hamstrings during the late swing phase of running gait. Observable during terminal swing. with front side mechanics Lengthens too much Slow with lengthened stride (excessive distance from foot strike to Center of Mass) OR Contracts too much Fast associated with shortened stride length (can be a response to increasing ) Involvement Hamstring(s) (often proximal insertion) Inferior patellofemora l Key Tests of Movement Quality Prone hip with knee Strength / Hamstrings Quadriceps (too much) Length Hamstrings /Soleus Structural Swayback posture (not necessarily structural) options Modify appropriately. Increase or decrease Decrease quadriceps use for knee Improve hip flexion during swing Improve control of terminal knee Options Home exercise MMT positions to isolate weak muscles: max, Hamstrings, hip flexors Functional strengthening in weight-bearing: stance Daily activities: standing posture exercises: Hamstrings & /soleus Hamstring Taping Eccentric hamstring training Step training with theraband 6

7 Key Stance phase Primary: and/or prolonged medial femoral Secondary: lateral tibial Swing phase Primary: tibial lateral Secondary: medial femoral Lateral trunk lean Slow / increased step length / long stance time Ankle/foot pronation Movement Pattern: Tibiofemoral Rotation Transverse plane impairment of the Knee Abnormal of the tibiofemoral observed in either the stance or swing phase of running gait. Key Tests of Movement Structural options Options Home Involvement Quality Strength / Length exercise Tibiofemoral Meniscus Patellofemoral ITB Proximal tibio-fibular Partial Squat: Double leg first as able stance: Observe stance and non-stance limbs Step-up / Step-down Prone knee flexion Deep hip lateral rotators gluteus medius Maximus Tibial medial rotators (Sartorius and Gracilis) tibialis TFL-ITB Hamstrings Hip lateral rotators (long) /Soleus Femoral anterversion or retroversion Genu valgum Increase (5-10%) / decrease step length Incline training Anterior trunk lean Decrease lateral foot during swing or stance Contract gluteals during stance MMT positions to isolate weak muscles: Deep hip lateral rotators (90 degrees of hip flexion), med, max, Tibial medial rotators Functional strengthening: stance /squat, lunge, side-stepping exercises: TFL- ITB Daily activities sitting posture, sleeping and stairs Patella taping: Medial glide Taping to prevent femoral medial and / or tibial lateral Basic foot orthotic 7

8 Key Knee flexion during loading Movement Pattern: Knee Flexion During Loading Sagittal plane impairment of the knee eccentric lengthening of quadriceps during the loading phase of gait, which is associated with decreased force attenuation by contractile tissue. Often will occur unilaterally when associated with an internal dysfunction of the knee such as a deficient ACL or ACL reconstruction. Can also occur bilaterally in the absence of internal knee dysfunction. ly referred to as Quadriceps Avoidance Rear foot strike pattern Slow /increased step length /long stance time Upright running posture Asymmetric (unilateral) Involvement Patellofemoral Meniscus Tibiofemoral Tibia Patellar tendon Lower back or hip Post-surgical tissue involvement Key Tests of Movement Quality Partial Squat: Double leg first as able Single or double leg hopping Patella accessory motion Prone knee flexion Strength / Quadriceps Length Quadriceps TFL-ITB Structural Patella Alta Tibiofemoral instability options Increase (5-10%) / decrease step length Use a rhythm to promote symmetry Incline training to shorten stride Cues to soften gait Options Home exercise MMT positions to isolate weak muscles particularly Gluteals Functional strengthening in weight-bearing: single leg stance, sidestepping Plyometrics to include single and double leg hopping, jump rope, and running in place exercises as indicated: Rectus femoris Patellar taping to prevent superior glide Patella tendon taping/ bracing Shoe wear (not a priority) Trial of trail running Address postoperative complications As needed 8

9 Key Increased foot / ground angle Movement Pattern: Abnormal Rear Foot Loading Sagittal plane impairment of the Foot Generally associated with a hard landing on the posterior most aspect of the heel. May be associated with other movement pattern impairments of running gait Loud / hard heel strike Slow backside mechanics/incr eased frontside mechanics Upright running posture Increased vertical displacement control of knee during terminal swing Involveme nt Anterior and lateral tibiofemora l Lower back Compartments of lower leg Anterior /lateral lower leg: Anterior shin splints Key Tests of Movement Quality Primarily related to the gait mechanics of running and walking of Muscle Strength / Abdominals gluteus medius Hip flexors Gastoc /Soleus Intrinsic toe flexors Toe extensors (dominant) of Muscle Length Structural options Variable Variable Increase (5-10%) / decrease step length Anterior trunk lean Incline training Increase hip and knee flexion Softer landing Options Home exercise MMT positions are used to isolate weak muscles: medius, / Soleus Plyometrics to include single and double leg hopping, jump rope, and running in place: Cues for soft landing exercises as indicated Shoe wear: Lower heel drop or barefoot could facilitate different strike pattern Contralateral pelvic drop 9

10 Key ly negative foot/ ground angle Heel may not reach the ground Movement Pattern: Abnormal Fore Foot Loading Sagittal plane impairment of the Foot Generally associated with a variable landing on the anterior most aspect of the fore foot. ly seen in individuals with sprint background and individuals with a learned forefoot pattern. Poor control of eccentric lowering at the ankle Forward lean of trunk Involvement Achilles tendon /Soleus Metatarsals Hamstrings Key Tests of Movement Quality Double and single leg hopping and walking mechanics Strength / /soleus (insufficient strength for forefoot strike requirements) Quadriceps Length /soleus Hamstrings Structural Variable options Decrease /lengthen step length Increase foot/ground angle (heel lower to the ground or midfoot strike) Decrease forward trunk lean May be able to gradually progress back to fore foot loading as strength /tissue tolerance improves Options Home exercise Eccentric (Achilles tendon) Intrinsic foot strengthening Functional strengthening to target Quadriceps and / Soleus exercises as indicated: / soleus and hamstrings Heel lift Tape to support contractile tissue Shoe wear: Higher heel may encourage earlier heel strike Cushioning to pad metatarsals Orthotic (with metatarsal pad if indicated) 10

11 Key or prolonged movement into pronation (calcaneal eversion, forefoot abduction, and dorsiflexion ) Movement Pattern: Abnormal Medial Plantar Loading Increased loading along the medial plantar surface of the foot during loading phase of running gait that may or may not associated with static alignment. Hip adduction/me dial Crossover landing pattern Femoral medial /Tibia l lateral Narrow knee window Involvement tibialis tendon Plantar Fascia Achilles tendon Anterior /lateral lower leg: Anterior shin splints Hallux/first ray Key Tests of Movement Quality Partial squat: Double leg as able stance Single or double leg hopping Strength / /Soleus tibialis Intrinsic toe flexors Proximal musculature may contribute: medius Length /Soleus tibialis (long) Structural Hallux Valgus Femoral Anteversion Genu valgus Flexible midfoot Talocrural capsular restriction options Shorten stride /increase Increase loading at middle/late ral foot Lean forward Options Home exercise Supinatory strengthening: / Soleus and Tibialis Intrinsic foot strengthening Proximal strengthening if testing implicates proximal involvement Orthotic: As needed Medial posting to match location of pronation (hindfoot/ midfoot) Taping to support source of symptoms Heel lift if /Soleus shortness rear foot strike Navicular Tibiofemoral exercises as indicated: / soleus Patellorfemor al 11

12 Key Insufficient force attenuation on loading /increased lateral loading (calcaneal inversion, forefoot adduction, plantar flexion) Movement Pattern: Abnormal Lateral Plantar Loading Impaired force attenuation during loading. The movement impairment is frequently associated with a rigid static alignment of the foot and ankle although may be associated with a runner s preferred movement pattern. Dynamic varus thrust of knee Involvement Base of 5 th metatarsal Fibularis longus/ brevis ITB Meniscus Plantar Fascia Stress fracture Key Tests of Movement Quality Partial squat: Double leg as able stance Single or double leg hopping Strength / Primarily structural however may demonstrate weak foot intrinsics (rely on bony support) Length Short EDL/EHL (assoc with hammer toe) Structural Genu varum Tibial varum Tibial torsion Hammer Toes options Softer landing Shift pressure toward middle /inside of foot Abduct hips (slight, if foot symptoms) Options Home exercise Intrinsic foot strengthening exercises as indicated: Toe extensors Basic foot orthosis /cushion Lateral posting (slight) typically at hindfoot to encourage pronation on loading Shoe wear: Crash pad, neutral to cushioned shoe Taping to support source of symptoms 12

13 Key Lateral pelvic tilt, trunk lateral flexion and/or lumbopelvic /long stride hip during terminal stance Asymmetric arm swing arm swing (swing in trunk instead of arms) Movement Pattern: Lumbar Rotation Transverse and / or frontal plane impairment of the lumbopelvic region Observed as pelvic and / or lateral pelvic tilt during running. Key Tests of Options Movement Structural options Home exercise Involvement Quality Strength / Length Lower back Sciatic nerve Forward bending Lumbar sidebending and in standing Prone hip Lower abdominals gluteus medius Rectus abdominis Hip flexors Scoliosis Unilateral hip anteversion or retroversion Symmetric arm swing Contract abdominals Increase (5-10%) /decrease step length Contract Pelvic floor Muscle strength/recruitment Lower abdominals Functional strengthening in weight-bearing: stance Daily activities to address: standing posture, sleeping, body mechanics exercises as indicated: Hip flexors Lumbar bracing or taping Ergonomics Breathing mechanics Lumbar 13

14 Key Anterior pelvic during the stance phase of gait Lumbar Hip hinge hip Increased rearfoot loading Foot strike anterior to center of gravity Movement Pattern: Anterior Tilt with Insufficient Hip Extension Sagittal plane impairment of the lumbopelvic region Observed as an anterior pelvic tilt during the stance phase of running gait. Key Tests of Options Movement Structural options Home exercise Involvement Quality Strength / Length Lower back Facet Nerve root Paraspinals Pelvis Forward Bend and return Supine single knee to chest Squat Prone knee flexion Abdominals (Rectus abdominis and lower abdominals) Short: Hip flexors (TFL, Rectus femoris, iliopsoas) Long: Abdominals Lordosis Increase Decrease stride length Contract abdominals Forward lean Contract pelvic floor Muscle strength/recruitment: Lower abdominals Standing weight shift/lean: Static progressing to dynamic Taping or back brace for external support. Increased stride length/ Lumbar 14

15 Key stride length excursion at ankle, knee, hip vertical motion of COG Erect trunk transverse plane motion Involvement ITBS Medial Tibial Stress Syndrome Achilles tendon Plantar Fascia Movement Pattern: Insufficient Propulsion The shuffler. Symptoms related to stresses associated with repetition/mileage. Key Tests of of Movement Muscle Strength / Structural options Quality Length Hopping (single leg, double leg) Squat (single leg, double leg) Abdominals Hamstrings/gluteals /Soleus *This individual may have more of a global impairment of strength or conditioning. Varies Varies Increase speed using interval strategy (run-walk) Encourage appropriate excursions. Options Home exercise Consider a strengthening using multi- functional exercises: -wall sit -squatting -side-stepping -lunge -toe walking -plyometrics Form running drills Cushioning or external support at specific involved structure 15

16 Key Early and / or excessive plantar flexion from mid-stance to terminal stance hip flexion from midswing to terminal swing Movement Pattern: Impaired Propulsion: Plantar Flexion with Hip Flexion: Sagittal plane impairment of the foot/ankle Propulsion occurs in reverse order (due to recruitment or strength) with early / excessive plantar flexion followed by knee next, and hip last. Increased vertical translation of COG Involvement Achilles /Soleus MTSS Exertional Compartment Syndrome Plantar Fascia Key Tests of Movement Quality Squat: double leg, single leg. Hopping/jumping Strength / medius Length Structural options /soleus NA Encourage appropriate excursions. Options Home exercise Hip strength Hill training 16

17 References: Barrios JA, Corssley KM, Davis IS. Gait retraining to reduce the knee adduction moment through real-time visual feedback of dynamic knee alignment. Journal of Biomechanics. 2010; 43: Cheung R, Davis, I. Landing pattern modification to improve patellofemoral pain in runners: A case series. JOSPT. 2011; 41(12): Chumanov ES, Wille CM, Michalski MP, Heiderscheit BC. Changes in muscle activation patterns when running step rate is increased. Gait Posture. 2012; 36: Crowell HP, Milner CE, Hamill J, Davis IS. Reducing impact loading during running with the use of real-time visual feedback. JOSPT. 2010; 40(4): Ferber R, Noehren B, Hamill J, Davis IS. Competitive female runners with a history of iliotibial band syndrome demonstrate atypical hip and knee kinematics. JOSPT. 2010; 40(2): Heiderscheit BC, Chumanov ES, Michalski MP, Wille CM, Ryan MB. Effects of step rate manipulation on mechanics during running. Med Sci Sports Exerc. 2011; 43: Liberman DE. What can we learn about running from barefoot running: An evolutionary perspective. Exercise and Sports Science Review. 2012; 40(2): Munteanu SE, Barton CJ. Lower limb biomechanics during running in individuals with achilles tendinopathy: a systematic review. J Foot Ankle Res. 2011:4:15. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinemaitcs, pain, and function in subjects with patellofemoral pain syndrome. Br J Sports Med. 2011; 45: Pohl M, Hamill J, Davis I. Biomechanicsl and anatomic factors associated with a history of plantar fasciitis in female runners. Clin J Sports Med. 2009;19(5):

18 Sahrmann SA. Movement System Impairment Syndromes of the Extremities, Cervical, and Thoracic Spines. St. Louis, MO: Elsevier Mosby; Wiley R and Davis I. The effect of a hip strengthening on mechanics during running and a single leg squat. JOSPT. 2011; 41(9): Souza RB. An evidence-based videotaped running biomechanics analysis. Phys Med Rehabil Clin N Am. 2016;27: