Evolution Running Assessment - Continuing Medical ... · 12/4/2010 3 Station 1 Station 1 ––Gait Assessment Gait Assessment Excessive forward rotation Pelvis Drop Adequte hip extension

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Running Assessment Running Assessment WorkshopWorkshopAnthony LukeAnthony Luke

MD, MPH, CAQ (Sport Med)MD, MPH, CAQ (Sport Med)UCSF PCSM Conference 2010UCSF PCSM Conference 2010

EvolutionEvolutionRunning boom in Running boom in the 70’s and 90’sthe 70’s and 90’sMen then womenMen then women% of women % of women runnersrunnersWheelchairWheelchair

Some numbersSome numbers26.2 miles26.2 miles42.195 km42.195 km2:03:59 Haile 2:03:59 Haile Gebrselassie (ETH) Gebrselassie (ETH) 3:10 3:10 ♂♂ / 3:40 / 3:40 ♀♀♀♀♀♀♀♀384 marathons in the 384 marathons in the USUS#7 of 10 Hardest things #7 of 10 Hardest things to do in sports to do in sports (USA Today, March 2003)(USA Today, March 2003)

Why did I get an injury?Why did I get an injury?

Too muchToo muchToo hardToo hardToo fastToo fast

…for your body !!…for your body !!

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Intake QuestionnaireIntake Questionnaire

The Ultramarathon ManThe Ultramarathon Man Biomechanical AnalysisBiomechanical Analysis

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Station 1 Station 1 –– Gait AssessmentGait Assessment

Excessive forward Excessive forward rotationrotationPelvis DropPelvis DropAdequte hip Adequte hip extensionextensionHip CircumductionHip Circumduction

•• Knee internal rotationKnee internal rotation•• Knee FlexionKnee Flexion•• Knee Extension Knee Extension •• Ankle dorsiflexionAnkle dorsiflexion•• Ankle plantarflexion Ankle plantarflexion with toe offwith toe off

•• Forward leanForward lean•• Stride lengthStride length•• Vertical displacementVertical displacement•• Static postureStatic posture

Station 1 – Gait Assessment

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Biomechanics of the Foot and Biomechanics of the Foot and AnkleAnkle

Foot dorsiflexed, Foot dorsiflexed, heel invertedheel inverted“Heel strike”“Heel strike”Heel Heel EVERTSEVERTS ��unlocks the unlocks the midfoot midfoot �� foot foot adapts to groundadapts to groundImpact greatest Impact greatest from heel strike to from heel strike to midstancemidstance Stance Phase (62%)


“Mid“Mid--Stance” or Stance” or “Foot“Foot--flat”flat”Leg externally Leg externally rotates and ankle rotates and ankle dorsiflexes dorsiflexes �� heel heel INVERTSINVERTS�� locks the locks the midfootmidfootFoot rigid leverFoot rigid lever Stance Phase (62%)


Plantarflexors Plantarflexors propel body propel body forwardforward

“Toe Off” involves “Toe Off” involves the 1the 1stst MTP jointMTP joint

“Double float”“Double float”Swing Phase (38%)

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Windlass MechanismWindlass Mechanism

Midstance Toe - off

Static AssessmentStatic Assessment

Station 2 Station 2 –– Strength and Strength and FlexibilityFlexibility

Posture (standing)Posture (standing)LordosisLordosisKyphosisKyphosisLeg lengthLeg lengthGenu Genu varum/valgusvarum/valgusSLS (30 sec)SLS (30 sec)



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StrengthStrength•• Single leg step downSingle leg step down•• AbdominalsAbdominals•• Hip flexorHip flexor•• Gluteus mediusGluteus medius•• Heel raises (20 Heel raises (20 reps/ea)reps/ea)

•• QuadsQuads•• HamstringsHamstrings•• Glut MaxGlut Max







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FlexibilityFlexibilityAchillesAchillesPopliteal AnglePopliteal AngleQuadriceps (prone)Quadriceps (prone)ITB (sidelying)ITB (sidelying)Hip Flexor (Thomas)Hip Flexor (Thomas)Spine (forward Spine (forward bend, standing)bend, standing)Spine (rotation Spine (rotation standing)standing)Gross Ankle Gross Ankle mobility: Anterior mobility: Anterior heel reachheel reach


FlexibilityFlexibilityAchillesAchillesPopliteal AnglePopliteal AngleQuadriceps (prone)Quadriceps (prone)ITB (sidelying)ITB (sidelying)Hip Flexor (Thomas)Hip Flexor (Thomas)Spine (forward Spine (forward bend, standing)bend, standing)Spine (rotation Spine (rotation standing)standing)Gross Ankle Gross Ankle mobility: Anterior mobility: Anterior heel reachheel reach

One Leg SquatOne Leg Squat Hip AbductorsHip Abductors

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F l e x i b i l i t yF l e x i b i l i t y

Popliteal Angle (Hamstrings)

ThomasTest (HipFlexor)

Ely’s Test (Quads)

Ober’sTest(ITB)

Arch typeArch type

FootwearFootwearNeeded to protect Needed to protect the feet and help the feet and help maintain maintain biomechanicsbiomechanicsHeel counterHeel counterAppropriate Appropriate cushioning solecushioning soleMidfoot supportMidfoot support

OrthoticsOrthoticsNeed to consider foot function and Need to consider foot function and foot structurefoot structure

Can help control motion in specific Can help control motion in specific planesplanes

Unload sensitive areasUnload sensitive areas

Improve efficiency of gaitImprove efficiency of gait

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Subtalar neutralSubtalar neutral OrthoticsOrthoticsMaterialMaterialLength (3/4 or Length (3/4 or full)full)LiftLiftPosting Posting (forefoot, (forefoot, midfoot, midfoot, rearfoot)rearfoot)

Courtesy of Alicia Knee, DPM, UCSF

Screening OrthoticsScreening Orthotics

Courtesy of Alicia Knee, DPM, UCSF

FootwearFootwearNeeded to protect Needed to protect the feet and help the feet and help maintain maintain biomechanicsbiomechanicsHeel counterHeel counterAppropriate Appropriate cushioning solecushioning soleMidfoot supportMidfoot support

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Shoe problemsShoe problemsTight shoes Tight shoes –– bunions, Morton’s bunions, Morton’s NeuromaNeuromaHigh heels High heels –– ball of feetball of feet

Nutrition Nutrition -- FuelFuelBody needs energyBody needs energy

CarbohydratesCarbohydrates–– 3030--60 g per hour60 g per hour–– Gels, bar Gels, bar

ProteinProtein–– 1.21.2--1.4 gm/kg body 1.4 gm/kg body weight/dayweight/day

How much to replace?How much to replace?Weigh yourself preWeigh yourself pre-- and postand post--runrunDrink more if lose more than 2% body Drink more if lose more than 2% body weightweightConsider heat load Consider heat load Check your urine (light like lemonade Check your urine (light like lemonade OK, dark like apple juice is low)OK, dark like apple juice is low)IMMDA suggest 400IMMDA suggest 400--800 ml fluid per 800 ml fluid per hourhourAnswer: Answer: Be individualBe individual

Achilles TendinopathyAchilles Tendinopathy

MechanismMechanismRepetitive Repetitive eccentric load on eccentric load on tendon tendon Pushing off, Pushing off, running, running, sprinting, sprinting, jumpingjumping

PresentationPresentationTender over Tender over achilles +/achilles +/--swellingswellingPain with Pain with resisted toe offresisted toe offPain with Pain with passive ankle passive ankle dorsiflexiondorsiflexion

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Risk FactorsRisk FactorsKhan KM, et al. Phys Sportsmed 2000.Khan KM, et al. Phys Sportsmed 2000.

Tight Achilles and plantar fasciaTight Achilles and plantar fasciaHyperpronationHyperpronationCavus footCavus footAdvancing age Advancing age -- decreased blood decreased blood flowflowOverweight Overweight Poor footwearPoor footwearWeak hip abductors and medial Weak hip abductors and medial quadricepsquadriceps

3 Basic P/E findings for 3 Basic P/E findings for TendinopathyTendinopathy

1.1. Tenderness on direct palpation Tenderness on direct palpation 2.2. Reproduction of pain with resisted Reproduction of pain with resisted

contraction (eccentric loading)contraction (eccentric loading)3.3. Reproduction of pain with passive Reproduction of pain with passive

stretchstretch

Conservative TreatmentConservative TreatmentREDUCE STRESSREDUCE STRESSModified activities, Modified activities, iceiceCalf / Achilles Calf / Achilles stretchingstretching

Hold each stretch for Hold each stretch for 30 seconds30 seconds

Soleus stretch

Gastrocnemius stretch

TreatmentTreatmentHeel liftsHeel liftsModify footwearModify footwearCustom orthoticsCustom orthoticsNight splintsNight splintsPT is a major keyPT is a major key

RarelyRarelySurgical Surgical debridementdebridement

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Physical Therapy for AchillesPhysical Therapy for AchillesAlfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med, Alfredson H, Pietilä T, Jonsson P, et al. Am J Sports Med,

1998; 26:3: 3601998; 26:3: 360--366.366.

RCT RCT –– eccentric exercises (3 x 15 eccentric exercises (3 x 15 reps, 2 times/day, 7 days a week x reps, 2 times/day, 7 days a week x 12 wks)12 wks)Results: Significant difference in Results: Significant difference in pain levels VAS 81.2 mm (+/pain levels VAS 81.2 mm (+/-- 18) to 18) to 4.8 mm (+/4.8 mm (+/-- 6.5) in 6.5) in 12 weeks12 weeks81% eccentric satisfied vs 38% 81% eccentric satisfied vs 38% concentric satisfiedconcentric satisfied

Eccentric Drop programEccentric Drop program

Patellofemoral painPatellofemoral painToo much pressure Too much pressure under the kneecapunder the kneecap

The Extensor The Extensor MechanismMechanismQuadricepsQuadricepsKneecapKneecapPatellar tendonPatellar tendon

Patellofemoral PainPatellofemoral PainMultifactorialMultifactorial

Too tight?Too tight?Too loose?Too loose?

Need good muscle Need good muscle balancebalanceQuadriceps Quadriceps strengthstrengthGood flexibilityGood flexibility

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Think BiomechanicsThink BiomechanicsAlignmentAlignmentConsider orthoticsConsider orthotics“Relative” symmetry“Relative” symmetryControl runningControl running

Worry when running technique altersWorry when running technique alters

Patellar tendinopathyPatellar tendinopathyPatellar tendinosisPatellar tendinosis“Jumper’s knee”“Jumper’s knee”

Degenerative Degenerative changes of the changes of the patellar tendonpatellar tendonActivityActivityAgeAge

Iliotibial band friction syndromeIliotibial band friction syndrome1010--21% of running overuse injuries21% of running overuse injuriesITB crosses the lateral femoral epicondyle ITB crosses the lateral femoral epicondyle at 30at 30°°Associated with “varus” moment at the Associated with “varus” moment at the kneeknee

Classic history: pain which is reproducible Classic history: pain which is reproducible after running a certain amountafter running a certain amountPainful click laterallyPainful click laterallySore especially going down stairsSore especially going down stairs

Ober’s TestOber’s Test

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ITB SyndromeITB SyndromeFix the underlying problemsFix the underlying problemsITB StretchingITB StretchingFoam rollerFoam rollerHip abductor and medial quadriceps Hip abductor and medial quadriceps strengthening exercisesstrengthening exercisesCorrect alignmentCorrect alignmentModify trainingModify training–– Avoid running on cambered road (low side)Avoid running on cambered road (low side)–– Avoid downhillAvoid downhill

Hip External RotatorsHip External Rotators

Hip AbductorsHip Abductors Marathon trainingMarathon trainingTrain with what you’ll Train with what you’ll compete withcompete withClothesClothesShoesShoesFluidsFluidsFoodFood

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Thank you.Thank you.

Documents

Evolution Running Assessment - Continuing Medical ... · 12/4/2010 3 Station 1 Station 1 ––Gait Assessment Gait Assessment Excessive forward rotation Pelvis Drop Adequte hip extension