Running has great benefits. Injury rate is high. Injury. Patellofemoral Pain Syndrome

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Amelia Bridges
5 years ago
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Female runners have unique risk profiles, biomechanics, and muscular

3D Trunk Training for the Female Runner Janice Loudon, PT, PhD, SCS,

high Injury Training errors* Volume (> 40 miles/week) Sudden change

Knee (42%) Foot and ankle (17%) Lower leg (13%) Hip/pelvis (11%)

Patellofemoral Pain Syndrome Most common knee ailment in long

1 Female runners have unique risk profiles, biomechanics, and muscular activation. 57% of race finishers in 2016 were female. 3D Trunk Training for the Female Runner Janice Loudon, PT, PhD, SCS, ATC Jenn Cumming, PT, MSPT Running has great benefits Injury rate is high Injury Training errors* Volume (> 40 miles/week) Sudden change in volume Previous injury* Biomechanics (excessive motion or forces) Knee (42%) Foot and ankle (17%) Lower leg (13%) Hip/pelvis (11%) Achilles tendon (6%) Upper leg (5%) Low back (3%) Other (2%) Patellofemoral Pain Syndrome Most common knee ailment in long distance runners Local vs. Regional interdependence Taunton et al, 2002 Kdtraining.worldpress.com 1

2003) Normal Internal Rotation Adduction Faulty movement pattern Dynamic valgus Why does this happen? What core mm group is responsible?

2 Proximal Influence PF kinematics depend on nonweightbearing versus weightbearing (Powers et al., 2003) Tibia on femur: patella moves Femur on tibia: femur moves Excessive femoral motion affects patellar alignment Proximal Influence Dynamic Q-angle (Powers, 2003) Normal Internal Rotation Adduction Faulty movement pattern Dynamic valgus Why does this happen? What core mm group is responsible? Gluteus medius/maximus Strength vs. endurance vs. movement fault Importance of Hip Strength Hip abduction is a known element to a strong, stable push off in walking and running; Mounds of research link hip abduction strength (and lack thereof) to running economy 2

Dynamic Knee Valgus Good evidence for hip strengthening Ireland et al., 2003 Fredericson et al.

a strength issue Individuals that display dynamic knee valgus had good hip strength. (Bolgla et al.

Proprioception Task-specific drills SERF strap (Powers) Stability thru ER of the femur Helps to

45 min sessions Pt education/instructions (rationale & key concepts of optimal movement) Task

3 Dynamic Knee Valgus Good evidence for hip strengthening Ireland et al., 2003 Fredericson et al., 2000 Selkowitz & Powers, 2013 Functional Strength SLS SLH Jump from a height Plyometrics Not always a strength issue Individuals that display dynamic knee valgus had good hip strength. (Bolgla et al., 2011) Need to address movement impairment!! How? Proprioception Task-specific drills SERF strap (Powers) Stability thru ER of the femur Helps to control femur position Task Specific Movement Training Salsich & Harris-Hayes Design 2x/wk for 6 wks; 45 min sessions Pt education/instructions (rationale & key concepts of optimal movement) Task selection and practice (high repetitions) Assessment of pain and movement quality Feedback Task progression Home program: practice moving optimally during all daily activities 3

Retraining: Willy & Davis, 2013 Case report 2 female runners PFPS 8 sessions of

in one study of 10 runners with patellofemoral pain, hip internal rotation

Moreover, pain during 30-minute runs was reduced by 86%, and loading rates were

The participants were instructed to contract their gluteal muscles and attempt to

subjects with patellofemoral pain syndrome. Br J Sports Med. 2011 Jul;45(9):691-6.

Cadence Stride rate = cadence x stride length Over-striding causes foot strike

4 Retraining: Willy & Davis, 2013 Case report 2 female runners PFPS 8 sessions of mirror gait retraining Decrease lateral tilt, hip adduction After gait retraining in one study of 10 runners with patellofemoral pain, hip internal rotation decreased by 23%, hip adduction decreased by 23%, and pelvic drop decreased by 24%. Moreover, pain during 30-minute runs was reduced by 86%, and loading rates were decreased by 20%. The participants were instructed to contract their gluteal muscles and attempt to run with their knee pointing straight ahead, while maintaining a level pelvis. Noehren B, Scholz J, Davis I. The effect of real-time gait retraining on hip kinematics, pain and function in subjects with patellofemoral pain syndrome. Br J Sports Med Jul;45(9): Running Form Slight forward Lean Decreases stress to PFJ (Teng & Powers, 2013) *** Cadence Stride rate = cadence x stride length Over-striding causes foot strike deceleration, increased joint loading Shorter stride PF loading Heiderscheit et al. The Abdominals Anterior part of 3d trunk stability What is the ideal to work the abdominals for the female runner? Working the abdominals 4

Rectus Abdominus Origin: Pubis Insertion: sternum and lower costal

contribution to control posture External Abdominal Oblique Origin:

Action: Flexion and Lateral flexion of vertebral column.

edu/~lkravitz/a rticle%20folder/abdominal.html http://www.

php/ site/articles/ab_exercise_myths/ Internal Abdominal Oblique

Insertion: Lower three ribs, xiphoid process, linea alba, and

http://www.ab-core-and-stomachexercises.com/internal-obliques.

six ribs, lumbar fascia, iliac crest, and inguinal ligament

5 Rectus Abdominus Origin: Pubis Insertion: sternum and lower costal cartilages Action: Flexion of vertebral column fast twitch minimal contribution to control posture External Abdominal Oblique Origin: Lower six ribs Insertion: Anterior iliac crest, pubis, linea alba Action: Flexion and Lateral flexion of vertebral column. Rotation and active expiration rticle%20folder/abdominal.html site/articles/ab_exercise_myths/ Internal Abdominal Oblique Origin: Iliopsoas fascia, anterior iliac crest, and lumbar fascia Insertion: Lower three ribs, xiphoid process, linea alba, and symphysis pubis Action: Flexion and rotation of vertebral column From Page, Frank, Lardner Transversus Abdominus Origin: Lower six ribs, lumbar fascia, iliac crest, and inguinal ligament Insertion: Xiphoid process, linea alba, and symphisis pubis Action: Flexion of vertebral column; controls IAP From McGill,

Abdominals Function Rarely works in isolation Work in all 3 planes Work as torque converters

shoulder elevation: LE TrA RA IO Deltoid EO MF Abdominals during Running Only 20 30% of

delayed (Hodges & Richardson, 1996,1998) Groin pain (Cowen, 2004) Reciprocal Arm and Leg To run

reaction forces of the lower limb (Dintiman & Ward, 2003) Reciprocal movement between UE and LE

6 Abdominals Function Rarely works in isolation Work in all 3 planes Work as torque converters stimulated by gravity, GRF, momentum, anticipation of loading and/or movement What is the real function? Form a hoop with thoracolumbar fascia to provide functional stability RA IO TrA EO Quick shoulder elevation: LE TrA RA IO Deltoid EO MF Abdominals during Running Only 20 30% of abdominal effort occurs during running (Mann, 1986) *in individuals with LBP, TrA activation is delayed (Hodges & Richardson, 1996,1998) Groin pain (Cowen, 2004) Reciprocal Arm and Leg To run efficiently and smoothly the trunk mm most stabilize the upper body from the moments and reaction forces of the lower limb (Dintiman & Ward, 2003) Reciprocal movement between UE and LE requires good abdominal synchronization Pelvic Control With each foot step: pelvis anteriorly rotates (sagittal plane); lateral tilts (frontal plane); rotates forward (transverse plane) Jay Dicchary, PT 6

Limiting Factors Poor posture Limited hip extension Limited thoracic motion Poor pelvic floor

in lumbar spine lordosis/pelvic tilting Unilateral hip hiking Lunge Anterior Posterior Lateral

Wide arms or excessive arm swing may indicate trunk weakness.

7 Limiting Factors Poor posture Limited hip extension Limited thoracic motion Poor pelvic floor activation Assessment Movement Pattern Endurance Quadruped opposite arm and leg lift Increase in lumbar spine lordosis/pelvic tilting Unilateral hip hiking Lunge Anterior Posterior Lateral Single leg balance with arm reaches Running Analysis Excessive movement of head, rounded shlds Wide arms or excessive arm swing may indicate trunk weakness. Increased impact loading Increased trunk rotation Increased lateral tilt during stance Increased anterior tilt during stance 7

Training Does core training affect running performance?

- 6 week Swiss Ball training core stability/running economy Improved core stability but not running economy Conclusion- injury prevention,

Phase Some supine and prone exercises for abdominals can create excessive compressive and shear forces (McGill, 2001) When abdominal mm

multifidi, IO, EO) Diaphragmatic breathing Table Exercises Pelvic bracing, neutral spine Diaphragmatic breathing improves core stability

8 Training Does core training affect running performance? Sato & Mokha 6 weeks of core training enhanced 5k time, did not improve running kinetics or SEBT scores. Training Does core training affect running performance? Stanton et al. - 6 week Swiss Ball training core stability/running economy Improved core stability but not running economy Conclusion- injury prevention, symmetry Training Phases Neuromotor starting point Stability - challenge Dynamic increase endurance and apply to skill (running) Neuromotor Phase Some supine and prone exercises for abdominals can create excessive compressive and shear forces (McGill, 2001) When abdominal mm work in isolation, they bend the spine forward and flex it or twist it to one side (Gray Cook) Exercise Examples Abdominal bracing (TA, multifidi, IO, EO) Diaphragmatic breathing Table Exercises Pelvic bracing, neutral spine Diaphragmatic breathing improves core stability (Akuthota) Single plane trunk exercises have limited value Stability Phase Various positions, ultimately in standing Exercise Examples Planks with leg lift Selkow et al Hands and Knee lifts 8

Dynamic Phase Decrease emphasis on abdominal bracing, emphasis on

kneeling Standing Single leg standing Dynamic Phase Dynamic Phase

toss Carry-over to Gait Retraining Arm swing mirror training Impact

9 Dynamic Phase Decrease emphasis on abdominal bracing, emphasis on stable and controlled mobility throughout the ROM Functional exercises coordination of all parts!! Examples PNF Chops/Lifts 3D spine motion Seated ½ kneeling Full kneeling Standing Single leg standing Dynamic Phase Dynamic Phase Secondary plane rotation- Resisted pressing/pulling Tick tock Surfer toss Carry-over to Gait Retraining Arm swing mirror training Impact loading Inertial sensors Trunk position mirror training What about dosage? Long distance running is endurance event, we need to dose appropriately for that. Muscle coordination/movement skills No weight/high repetitions Power 3-6 sets, 2-5 reps as fast as possible Strength 2-4 sets, 5-8 reps, high RM Endurance 1-3 sets, reps, 60%RM Thank You Hawks 9

Keys to the Office Based Evaluation of the Youth Runner

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