WHY DOES IT HURT WHEN I RUN?

Transcription

1 WHY DOES IT HURT WHEN I RUN? Stuart Lisle, MD Primary Care Sports Medicine Physician Oklahoma Sports and Orthopedics Institute OPTA Conference 4/2/16

2 MY CREDIBILITY

3 OBJECTIVES 1. Learn how to recognize the common running injuries in the adult and pediatric populations 2. Learn how to manage these injuries 3. Learn when to refer

4 OVERVIEW Epidemiology Prevention Injuries of the hip and pelvis Injuries of the knee Injuries of the lower leg, ankle and foot Other issues

5 EPIDEMIOLOGY Difficult to establish exact injury statistics NCAA does not keep statistics for Track & Field Yearly incidence of 29.5% to 56% Risk factors for injury include: -inexperience (<3yrs) -increased miles per week (>19, and another threshold >40) and higher intensity -increased risk of stress fractures at >20 mpw -previous injury in past 12 months -recent transition in training Unclear or unrelated risk factors: age, gender, flexibility, running shoe type

6 AMERICAN ACADEMY OF PEDIATRICS Risks in Distance Running for Children - Policy Statement in 1990 Cited concerns about prepubescent athletes training too much (10-15 miles daily) and for marathons Youth marathoners still fairly rare, and many major marathons have minimum age requirements (16 for Chicago and 18 for Boston)

7 LOCATION OF INJURY Most are of overuse syndromes Knee (40%) Lower Leg (20%) Foot and ankle (20%) Hip and pelvis (15%) Back (5%)

8 QUOTE Top level runners are always on the verge of breakdown from injury or of a breakthrough performance -Christopher McGrew

9 NOT THAT BAD Injuries are very common in running, but annual incidence is still 2-6 times lower than in other sports

10 PREVENTION Increase mileage/training carefully -consider intensity, mileage, running surface -the 10% rule? Wear proper shoes or don t -just make sure they fit -orthotics Core strengthening Proper nutrition, sleep, recovery Preparticipation exam -ask about previous injuries -Screen for Female Athlete Triad Other fancy devices?? -compression sleeves, socks, pants, body suits -foam rollers, the stick, kinesiology tape

11 ALMOST WORLD RECORD (2:04:00)

12 CASE 1 16 yo female who is a distance runner on her high school track team comes in complaining of a nagging anterior groin pain for the past several weeks. She has trained very hard over the winter in hopes of competing for a state title in the two mile run this spring. On her exam, she has a little discomfort with extremes of ROM at the hip and slight discomfort with palpation over the anterior groin, but otherwise normal.

13 FEMORAL STRESS FRACTURES Femoral Neck- two locations -Superior (tension sided) -Inferior (compression sided) Femoral Shaft Diagnoses often delayed- need high clinical suspicion Xrays typically normal initially Bone Scan or MRI more sensitive

14 FEMORAL NECK Inferior (compression sided) often treated conservatively Superior (tension sided) more at risk to progress to complete fracture Both initially treated with non-weight bearing until pain free Follow closely with imaging, as both have possible need of surgical treatment

15 FEMORAL SHAFT More common than neck fractures Sudden increases in pain that progresses to include activities of daily living Pain with palpation of groin, hip or thigh Positive hop test or fulcrum test

16 FEMORAL SHAFT CONT Protected weight bearing with crutches until pain free (1-4 weeks). Or NWB x6wks May begin rehab once pain free (often at 2 weeks) with minimal weight bearing activity Full recovery varies, but typically 5-10 weeks

17 CASE 2 14 yo male runner comes in to your clinic with progressive pain at his anterior pelvis. He is new to running this year, but has been training hard to catch up with his teammates.

18 PELVIC APOPHYSEAL INJURIES Acute- sudden, powerful contraction causes pop and avulsion injury More common in sprinters, jumpers Tender on palpation Xrays show avulsion Chronic- repetitive eccentric contraction causes apophysitis More insidious; confused for hip flexor strain Tender on palpation Xrays may be normal; MRI may help

19 PELVIC APOPHYSEAL INJURIES ASIS- sartorius AIIS- rectus femorus Iliac Crest- internal and external obliques, transverse abdominus, tensor fascia lata, gluteus medius

20 PELVIC APOPHYSEAL INJURIES Treatment most often conservative Acute avulsions may require extensive PT and significant injuries may require non-weight bearing Chronic may be hard to differentiate from muscle strains, but both treated similarly with rest, ice, gentle stretching and gradual return to activity

21 CASE 3 35 yo female runner presents to you with complaints of anterior knee pain for the past several weeks. It bothers her when running, after running, when going down stairs and after sitting for prolonged periods of time.

22 PATELLOFEMORAL PAIN SYNDROME Runners Knee - number one complaint in runners clinics Differentiate from Chondromalacia Patella where an actual articular cartilage defect is present Insidious onset of vague anterior knee pain; may have mild swelling and popping Contributing factors include: extensor mechanism malalignment (VMO weakness and VL hypertrophy), patella alta or baja, increased Q-angle, tight lateral structures (IT Band, lateral retinaculum), weak hip abductors, extensors and external rotators

23 PFPS CONT Exam -anterior, peripatellar and subpatellar pain -evidence of extensor mechanism problems -positive compression test -foot malalignment or leg length discrepancy

24 PFPS Treatment -PRICE acutely -PT to correct biomechanical factors -improve flexibility of IT Band, hamstrings, quadriceps, calves -Strengthen VMO, hip abductors, extensors, external rotators -Taping, bracing, orthotics MRI to look for articular defects if failure to improve (may have other treatment recommendations )

25 CASE 4 27 yo male comes to your office with complaints of lateral knee pain for the past few weeks. Pain gets a little better after warming up but is worse when running downhill.

26 ILIOTIBIAL BAND SYNDROME Tendinopathy results from repetitive friction of the ITB at the lateral femoral condyle Contributing factors include: increased hip adduction and internal rotation, excessive supination or pronation, varus position of knee, tibia and foot

27 ITBS Exam -tight ITB on Ober s (what runner isn t) -pain on Noble s Treatment -PRICE, meds, iontophoresis -foam roller, massage or myofascial release (rolfing) -flexibility and strength of hips -taping and bracing -consider MRI for recalcitrant cases (look for lateral meniscus) -occasional surgical for very resistant

28 ITBS CONT.

29 CASE 5 13 yo male runner comes in complaining of pain in the anterior knee off and on for months that has been progressively getting worse. He now notes a slight bump on his knee.

30 TRACTION APOPHYSITIS Sinding-Larsen-Johansson sydrome -apophysitis at inferior pole of patella Osgood-Schlatter disease -apophysitis at tibial tubercle Both more common in jumping and kicking activities Associated with inflexibility at quadriceps and hamstrings Most common at periods of rapid growth

31 SLJ AND OS Pain on palpation and with resisted knee extension May see fragmentation or irregularity on xray Treatment is self-limited with relative rest and stretching of quadriceps and hamstrings Can try compression sleeves or straps and medications May resolve quickly or linger off and on until growth spurt stops Rarely ossicle excision needed (typically as adult)

32 CASE 6 18 yo female comes to your clinc complaining of bilateral shin pain which has progressively been getting worse. She says she has this problem every season when she runs, but this year it is not going away.

33 SHIN SPLINTS AKA Medial Tibial Stress Syndrome Tenderness over the distal third of the posteromedial tibia Thought to be periostalgia or tendinopathy along tibial attachment of soleus or posterior tibials muscles Important to differentiate from stress fracture and exertional compartment syndrome May progress to stress fracture if not properly detected and treated

34 SHIN SPLINTS CONT Exam -dull ache in medial shaft with activity -tenderness to palpation along shaft -normal neurovascular exam and xray Treatment -PRICE -correct biomechanical factors (muscle imbalances of plantar and dorsiflexors, invertors; pes planus or varus; leg length descrepancy) -proper shoe wear, avoid running on crowned or uneven surfaces -return to activity guided by symptoms

35 TIBIAL STRESS FRACTURE Most common stress fracture in runners Pain acutely worsened after prodrome period; pain with ADLs Differentiated by focal tenderness on palpation; positive tuning fork test Xrays may be positive after 4-6 weeks MRI more sensitive and may help in determining length of recovery (stress rxn vs fx) Treatment includes relative rest, cast boot if pain with walking, and otherwise same at shin splints

36 TIBIAL STRESS FRACTURE CONT Medial tibia RTP typically 6-8 weeks Anterior tibia more critical, with potential progression to complete fracture -more common in jumping athletes - dreaded black line -conservative treatment may take 6-8 months -surgical intervention may be needed

37 EXERTIONAL COMPARTMENT SYNDROME Chronic reversible ischemia due to noncompliant osseofascial compartment with muscle volume expansion during exercise Recurrent and reproducible leg pain, which increases if activity continues and resolves with discontinuation Often described at tight, cramp-like squeezing ache over a specific compartment Four major compartments of the lower leg: -Anterior (45%) -Deep Posterior (40%) -Lateral (10%) -Superficial Posterior (5%)

38 CECS CONT Exam -Gold standard is compartment pressure testing -Post exertional MRI; MRI to rule out other causes Treatment -relative rest, NSAIDs, stretch/strengthen involved muscles, orthotics -PT to change biomechanics (may try midfoot strike) -refer for fasciotomy for persistent cases and progressive neurologic deficits

39 CASE 7 32 yo male presents with pain in the back of his ankle which has been bothering him for the past 2 months after training for the La Luz trail race.

40 ACHILLES TENDINOPATHY Spectrum including tendonitis, tendinosis, peritendinitis (bursitis), tear Tendonitis and tear more acute, while tendinosis more common and chronic Pain typically 2cm above insertion of achilles on calcaneus Contributing factors: tight heel cord, ankle instability, weak dorsiflexors/plantarflexors, excessive uphill running

41 ACHILLES TENDINOPATHY CONT Negative Thompson test to rule out complete tear -with patient prone, knee at 90 degrees, squeeze calf: lack of plantar flexion is positive test Treatment with calf stretching, eccentric strengthening, heel lifts, pronation control, NSAIDs, relative rest, ice, nitro patches Consider MRI for resistant cases Surgery typically needed for complete tear, but also sometimes for recalcitrant tendinosis (debridement)

42 SEVER S DISEASE Calcaneal apophysitis- pain at the site of the achilles tendon insertion on the calcaneus 8-15 yr olds Intermittent or continuous pain at beginning of season; improves with rest Positive squeeze test or Sever s test (pain on tip toes) Lateral xray shows characteristic changes at aphphysis Treatment with rest, activity modification, ice, NSAIDs, heel lift; if resistant- night splint and maybe short leg cast

43 CASE 8 47 yo female runner comes to you clinic with pain in her heel for the past month which gets better after warming up, then worse again later in the run. It is exquisitely painful with her first step out of bed in the morning.

44 PLANTAR FASCIITIS Microtears of the plantar fascia insertion at the calcaneus causing pain at the heel or arch, worse with first steps out of bed. Contributing factors: tight calves, plantar fascia, obesity, excessive time on one s feet, overpronation.

45 PLANTAR FASCIITIS CONT Exam shows pain in plantar medial heel; pain with resisted toe flexion and passive extension; no bony tenderness Radiographs may demonstrate heel spur (usually insignificant)

46 PLANTAR FASCIITIS CONT Treatment -NSAIDs, ice massage, stretching - heel cushioning, night splint, orthotics -strengthen intrinsic foot muscles (towel exercise) -Judicious injections Often takes up to a year to get better Surgery for resistant cases (various methods)

47 TREATMENTS

48 CASE 9 25 yo male runner presents to clinic with pain over the top of the foot It had been nagging for weeks, but got acutely worse

49 METATARSAL STRESS FRACTURE Insidious onset, worse with increased activity Focal tenderness, localized edema Contributing factors: flat feet, rapid increase in training Runners typically have more distal fractures Xrays often negative early

50 STRESS FRACTURES OF THE FOOT Critical -Proximal 5 th MT (Jones Fracture) -Navicular -1 st MT Slower healing, higher rates of non-union Often non-weight bearing for extended time or surgery needed (Jones fracture) Non-Critical -2-4 MT -5 th MT avulsion -Calcaneal Rest and stiff-soled shoe or cast boot Gradual progression after 6-8 weeks

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52 OTHER INJURIES OF THE FOOT Iselin dieaseapophositis of peroneus brevis insertion on 5 th metatarsal Xray shows widening of apophysis on inferior lateral base of MT Line seen parallel to 5 th Met diaphysis (as opposed to more perpendicular Jones Fx) Rest, ice, stretch and strengthen peroneals, orthotics, boot Freiberg disease (infraction)- osteochondrosis of 2 nd metatarsal head Adolescent and young females Local tenderness and pain with MTP ROM Xrays initially normal, then show flattening at 2 nd MT head Protective footwear and NSAIDs; surgery rarely needed

53 PICTURES

54 CASE yo male comes into clinic with concerns about diarrhea when he runs. He reports this problem is worse with hard workouts and races

55 RUNNER S TROTS Common (30% of runners in a 10k race in one study) Multiple Etiologies -Anxiety -Increased GI Motility -Dietary factors (fiber, lactose, sorbitol, fructose, caffeine, Vitamin C)

56 RUNNER S TROTS CONT Treatment (prevention) -Encourage BM; light meal a few hours before competition with light jogging to stimulate gastrocolic reflex -improve hydration before and during (decrease ischemia) -increase or decrease fiber -avoid triggers -decrease training and then build back up

57 GENERAL POINTS Remember Prevention! Certain injuries require refrain from runningstress fractures, radiculopathy Most allow for some level of training -pain/discomfort should be mild -pain that eases after warming up is generally benign -pain that progressively worsens is typically not -should not run if limping or gait is altered Supplement with cross-training Most recommend to change shoes every miles

58 MORE INFORMATION Position Statement from AMSSM on Overuse Injuries and Burnout in Youth Sports healthychildren.org Is your child ready for sports? m/health-injuries

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60 REFERENCES baa.org chicagomarathon.com Madden, Christopher C. et al. Netter s Sports Medicine O Connor, Francis G. et al. ACSM s Sports Medicine, A Comprehensive Review Risks in Distance Running for Children. Pediatrics. Vol 86. No 5. November 1, 1990.

61 QUESTIONS?