Injury: the Big 6 Evidence-Based Exercise for the Injured Runner Jason Lunden, PT Board Certified Specialist in Sports Physical Therapy Excel Physical Therapy Bozeman, MT Rates 20-90% Knee injuries: 42% PFPS: #1 injury (16%) ITBFS: #2 injury (8%) Lower leg/ankle/foot: 36% Plantar Fascia: #3 injury MTSS: #4 injury Achilles: #5 injury Stress Fx: up to 20% 2 Matheson et al., AJSM 1987 van Mechelen W et al. Sports Med 1992 Taunton JE et al. BJSM. 2002;36:95-101 Functional Progression Functional Progression Single Limb Squat Lunge Even surface Uneven surface perturbations Double limb Squat Functional Progression Squatting Athletic Position Base position Uniplanar Biplanar Triplanar Spine/pelvis: Neutral spine Anterior pelvic tilt Chest over knees Lower Extremities: Triple flexion Hip: initiates movement Knee: control in 3 planes Ankle: maintain foot position 1
Squatting Mechanics: Faults Squat Mechanics Lunging Lunge Progression from Squats Strength/Control Sport Specific Movement Pattern Escamilla RF et al. JOSPT 2008; 38: 681-690 Distefano LJ et al. JOSPT 2009; 39:532-540 Single Leg Squat Single Leg Squat challenge Proprioception! Assess as with squat 2
Functional Progression: plyometrics Functional Progression: plyometrics Hop Leap Jump SL Squat Lunge Squat Hop Leap Jump Jumping Jumping 2 foot take-off/landing Plyometric Squat Squat mechanics = Jump mechanics: Triple joint flexion Equal weight-bearing Soft/quiet landing Progression: Drop Down Focus on landing Jump in Place Take-off/landing Repetitive Jumps in Place Add overhead reach Squat Jumps/Broad Jumps toe midfoot when in place Heel toe for distance Jumps with Rotation Box Jumps Leaping Leaping Alternate foot take-off/ landing strength and control Common Mvmt in Sport 3
Hopping Hopping Take-off/landing same leg Plyometric SL squat strength, control, power Front of knee Patellofemoral Pain Syndrome Weak Hips Over Pronation Weak Quads My Knee Hurts Training error: increased mileage Side of knee ITB Friction Syndrome Weak Hips Over Pronation My Knee Hurts Training error: hills, track, country roads 21 22 Abnormal Gait Mechanics increased hip IR for PFPS decreased hip abd & ext strength increased hip add for ITBFS decreased hip abd strength Strength (weakness!) Injured athletes are likely to have hip abductor, flexor, and external rotator weakness Ireland et al. JOSPT. 2003; 33:671-676;Leetun et al. Med Sci Sports Ex. 2004;36:926-934; Niemuth et al. Clin J Sports Med. 2005; 15: 14-21 Weak hip abd associated with increased hip adduction during running (increased with fatigue) in athletes with PFPS Dierks et al. JOSPT. 2008; 38: 448-446 ITBFS sx resolution paralleled the return of hip abd strength Fredericson et al. Clin J Sports Med. 2000; 10:169-175 PFPS sx resolution & improved running mechanics with hip abd & ER strengthening Earl JE et al. AJSM 2011; 39:154-163 23 4
Hip Abduction--> Glute. Med Level I: RCT Level II: RCT Level III: Retrospective or Case controlled Studies Level IV: Case Series LEVEL V: Expert Opinion SL Clamshell (40% MVIC) SL Plank (Bridge) (74% MVIC) SL SLR (~40% 81% MVIC) Standing Isometric Standing pelvic drop/lift (57% MVIC) Lateral band walk (60% MVIC) Maintain level pelvis (coronal plane) with lunge, single leg squat, plyos etc 26 Bolga LA et al. JOSPT 2005, Ekstrom RR et al. JOSPT 2007, Ayotte NW et al. JOSPT 2007, DiStefano LJ et al JOSPT 2009 27 28 29 30 5
Hip Extension--> Glute Max isometric (butt squeeze) Prone leg lift bridge (supine) progression (40% SL) Squat progression (pay attention to hip flexion--> butt back!) (60% MVIC) Deadlift (59% MVIC) 31 32 Bolga LA et al. JOSPT 2005, Ekstrom RR et al. JOSPT 2007, Ayotte NW et al. JOSPT 2007, DiStefano LJ et al JOSPT 2009 33 34 Bird Dog Start on your hands and knees, and draw your abdominals up. Lift 1 arm and your opposite leg while keeping your back straight and hips level. Hold each position x 2 easy breaths. Alternate sides and perform 5-15x each side Perform 3-4 times / week. 35 36 6
Basic Squats Advanced Squatting Mechanics: Faults Stand with feet hip width apart. Slowly sit back into your hips as you sink down into a squat. Allow the trunk to angle forward as you squat down. Do not allow the knees to push forward beyond the toes. Advanced: perform on 1 leg while maintaining proper form 10-15 reps, 2-3 sets; 3-4 times/week 37 Trunk Posterior pelvic tilt/ lumbar kyphosis lordosis Hip Hip Flexion Varus/Valgus Knee anterior translation Foot Pronation NBOS WBOS 40 41 42 7
Medial Tibial Stress Syndrome (Shin Splints) Etiology: Poor cushioning Over pronation High arches Weak Hips! Training Errors: Running with fatigue, increased mileage Medial Tibial Stress Syndrome (Shin Splints) Treatment: Rest: Cross training (ie focus on NWBing) Support: Proper shoe design; orthotics Stretch: Soleus, soft tissue massage Strengthen: control of pronation Gastroc & Soleus Stretches Plantar Fasciosis Etiology: Tight calves Over Pronation Weak foot muscles Stand next to a wall with your feet staggered and the toes of your rear foot pointed straight ahead. Keeping the heel of the rear foot on the ground lean forward over your front foot until you feel a medium stretch in the back of the calf Training error: increased mileage Perform with the back knee straight and with the back knee bent Hold 30-45 seconds, 2-3 sets (each stretch); 2 times/day 45 46 Plantar Fasciosis Treatment: Stretching: gastroc/soleus, plantar fascia Night splint(s) for chronic (6 months) Manual Therapy: STM and joint mobilization Iontophoresis: dexamthosone or acetic acid Support: orthotics RCT Level I evidence Group I: - Ionto (dex), U/S, ice, and intrinsic strengthening Group II: - MT & self mobilization Both groups performed gastroc/soleus stretching 8
Results: Both groups improved at 4 weeks and 6 months The MT group had significant improvements over the modality group NNT = 4 patients Results: Both groups improved at 4 weeks and 6 months The MT group had significant improvements over the modality group NNT = 4 patients My Achilles is Killing Me! Architectural changes Decreased tendon compliance Inefficient force transfer Pain reduction Return to activity Normalization of tendon structure (Fahlstrom M et al 2003.) Disappearance of neovessels (Ohberg L et al 2001) Eccentrics! Alfredson H et al. BJSM 2007 Pain reduction Return to activity Normalization of tendon structure (Fahlstrom M et al 2003.) Disappearance of Neovessels (Ohberg L et al 2001) Eccentrics! Repeat 45x 2x/day for 12 weeks Progression: perform the exercise until it becomes pain-free. Add weight (hand held or backpack) until exercises are painful (3-4/10) again Eccentrics! 9
No difference b/w rehab with activity modification and rehab alone Better yet. Treatment of the Injured Runner Symptom management Address muscular imbalances Add other triceps surae strengthening Functional progression is Key! Use your PT toolbox 10