Managing the runner with knee OA

Managing the runner with knee OA Dr Christian Barton PhD, Bphysio (Hon), MAPA, MCSP Sport and Exercise Medicine Research Centre, La Trobe University, Melbourne, Australia Clinical Director and Physiotherapist, Complete Sports Care, Melbourne, Australia Associate Editor British Journal of Sports Medicine and Physical Therapy in Sport

A little about me

1. Loves running, and has run all her life 2. Left knee pain on and off past 2 years following a fall 3. Running is Ok, until > 5km 4. Lots of pain recently trying to train for ½ marathon 5. Intense pain for 3-4 days after 15km run recently 6. Recently tried changing strike pattern to forefoot strike no help

1. Extruded medial meniscus, with horizontal tear periphery of the posterior horn and tiny vertical tear free edge posterior horn. 2. Focal tiny chondral cleft articular cartilage MFC. 3. Mild to moderate chondromalacia patellae. 4. Moderate joint effusion and synovitis. 5. Complex Baker's cyst, with likely rupture inferiorly.

Physical activity and exercise therapy not only improve symptoms and impairments of OA, but are also effective in preventing at least 35 chronic conditions and treating at least 26 chronic conditions, with one of the potential working mechanisms being exercise-induced antiinflammatory effects.

RISKS BENEFITS

RUNNING? 1. Pain? 2. OA progression? RISKS BENEFITS

Risk of OA 1 study reported no effect on cartilage defects 1 study reported positive effects on glycosaminoglycans (GAG) OA present 6 studies reported no effect on cartilage thickness, volume or defects 1 study reported a negative effect + 1 no effect on GAG 2 studies reported a positive effect + 2 no effect on collagen.

25 studies Competitive or recreational? Specifically reported that the runners were professional, elite, or ex-elite athletes, or in any case in which runners represented their countries in international competitions.

The right amount of load is good! Andriacchi, T.P., et al., A framework for the in vivo pathomechanics of osteoarthritis at the knee. Ann Biomed Eng, 2004. 32(3): p. 447-57.

RUNNING? Prevent at least 35 chronic conditions (Booth 2012) 1. Pain? 2.??OA progression??

Principle of RISK management R educe overall load I mprove capacity to attenuate load S hift the load K eep adapting to the capacity and goals of the runner

Load management

Load management 2. Gradually adapt capacity to handle load 1. Reduce the load

Why does it still hurt!?! Loading may be biggest issue Load management is vitally important

Pain - Increased stress - Decreased capacity Maladaptive Behaviours - Physical changes - Non-physical changes

Key considerations in knee Proximal - Pelvic drop - Hip control - Knee extension/flexion Distal - Foot strike pattern - Over-striding

1. Lower step rate 2. Landing further from centre of mass (i.e. over-stride) 3. Greater centre of mass vertical excursion 4. Greater ankle dorsiflexion at foot strike

Increase step rate

Addressing over-stride with step rate

Who Mixed-sex cohort of runners with PFP > 3 months and aged 18-45 Running a minimum of 10KM/week What 6 weeks increasing by 7.5% (metronome) Faded feedback design 1 structured session per week Pain and lower limb kinematics measured

Biomechanics are not simple Three categories: - Kinematics (motion we can see and assess) - Kinetics (forces which drive the motion) - INJURY - Neuromuscular/EMG function (control of kinematics and kinetics) Is the issue kinematics or neuromotor?

Life is a bell curve

Running retraining? 1. Identifying any theoretical (abnormal) running mechanics which may be contributing to tissue overload 2. Establish if running mechanics can be altered 3. Facilitate the desired running mechanics changes and encouraging motor learning to ensure maintenance of any change CHANGE THE PATH OF LEAST RESISTANCE

Is Running Retraining evidence based? Our synthesis of published evidence related to clinical outcomes and biomechanical effects with expert opinion indicates running retraining warrants consideration in the treatment of lower limb injuries in clinical practice

Methodolgy

Patellofemoral Pain Limited Evidence (Noehren2011; Willy 2012) Evidence Biomechanics Intervention 8 sessions (2 weeks) Visual and verbal feedback to reduce hip adduction Outcome Reduce pain and improve function

In clinical practice?

There were no significant adverse events that occurred in either group. Subjects in the experimental group reported calf soreness during the retraining phase. However, this subsided by session six for all of the subjects in the group. Two subjects in the experimental group (25%) reported ankle soreness associated with the new running gait at the one-month follow-up. Subjects described it as an ache that quickly subsided after they discontinued running.

Transition from rearfoot to forefoot strike

Highly researched gold standard

1.2 1.6⁰ of internal femur rotation for every 5⁰ of anterior pelvis tilt

Manage RISK in running

Manage RISK in running Principle of RISK management R educe overall load General strategies - Reduce running - Address over-stride - Increase step rate

Modified from Thomeé (1997)

Manage RISK in running Principle of RISK management R educe overall load General strategies - Reduce running - Address over-stride - Increase step rate I mprove capacity to attenuate load - Graduated loading - Strength and Conditioning - Muscle activation cues

Graduated loading

Manage RISK in running Principle of RISK management R educe overall load General strategies - Reduce running - Address over-stride - Increase step rate I mprove capacity to attenuate load - Graduated loading - Strength and Conditioning - Muscle activation cues S hift the load (Most retraining strategies) - Reduce anterior pelvic tilt (gluteals and core) - Increase knee flexion (quads) - Transition to midfoot/forefoot strike (calf) Does the individual possess capacity? K eep adapting to the capacity and goals of the runner

Take Home 1. Running is good for you 2. Manage RISK in the injured runner 3. Load management + getting/staying strong is key 4. Change sagittal plane running mechanics first 5. Consider barriers that prevent desired changes

Questions? c.barton@latrobe.edu.au