3/24/2017

1

Treatment of the

injured runner:

Evidence for clinical

applications

Richard Willy, PhD, PT, OCS

Assistant Professor of

Physical Therapy

East Carolina University

Greenville, NC USA

willyr@ecu.edu

Twitter: @rwilly2003

The presenter has no financial relationships or

product endorsements to disclose

Outline

1. Epidemiology of running injuries

2. Envelope of function

3. Classifying running mechanics pertinent to injury

4. Gait retraining

5. Therapeutic exercise: for runners

6. Return to running

19.4%-79.3% incidence of

running injuries van Gent 2007

If obese and novice, highest risk if

initiate running with > 3km in

the 1st week! Nielsen 2014a,b

Number 1 predictor: Past injury! van der Worp 2015

Epidemiology of running injuries

Patellofemoral pain

48.8% of knee injuries

Female: 62%

Male: 38%

Often begins in adolescence, continuing

Into adulthood => PFOA? Rathleff, 2013, Crossley 2011

Where do runners get injured? Taunton 2002, Callahan 2000, Matheson 1987, Lopes 2012

Tibial stress injuries

(Tibial stress syndrome)

2.2-7.8%

Female: 73.6%

Male: 26.4%

6 weeks-9mo loss of runningBennell and Brukner, 2005

Iliotibial band

syndrome

1.9-12%

Female: 62%

Male: 38%

Leading cause of

lateral knee painTaunton 2002

Achilles tendinopathy

9.1-10.9%

Female: 42%

Male: 58%

Up to 45% fail treatmentSayana 2007

Running

Injury

Structure

Mechanics

Physiology,

Genetics

Central,

psychosocial

Tissue

qualities

Training

loads

In 12-16 weeks prior to a targeted race:

Injury: #1 reason nonstarters (42%) Clough 1987

Focus on anatomy or mechanics?Willy 2013

Distinctly different

mechanics for

Iliotibial band

syndrome

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2

Treadmill vs. overground mechanics

Kinematics and spatiotemporal measures Fellin et al., 2010, Riley 2008, Willy 2016

Slightly shorter stride

Tend to land with a flatter foot (less dorsiflexed)

Otherwise, very little difference

Common running deviations

Proximal mechanism Overstriding

mechanics

Proximal mechanism: Associated injuries

Most Common Running Injuries

% Running Injuries

Female/Male

Patellofemoral Pain 22% 62%

Iliotibial Band Syndrome

11% 62%

Plantar Fasciopathy 10% 46%

Tibial Stress Injuries 7% 57%

Achilles Tendinopathy

10% 42%

Patellar Tendinopathy

10% 43%

Taunton, 2002

Proximal mechanism in females with PFP

Contralateral Pelvic Drop

Hip Adduction

Hip Internal Rotation

Knee abduction

Demonstrated in cross-sectional

and prospective studies (Willy et al, 2012, Willson et al., 2008, Souza et al, 2009,

Noehren et al. 2013)

Axial view

of PFJ

Lat Med

Lateral tracking of the patella

Proximal mechanism: IT Band Syndrome

ITB: Lateral hip and knee stabilizerTerry 1986

Contralateral pelvic drop and Hip adduction Noehren 2007, Hamill 2008, Ferber 2010

Impingement primarily at the lateral femoral

condyle

Proximal mechanism: Stress fractures Pohl 2008

Tension

Compression

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The effect of a hip strengthening program on mechanics during running and during a

single leg squat Willy RW, Davis IS. J Orthop Sports Phys Ther. 2011 Sep;41(9):625-32.

0

2

4

6

8

10

12

14

Hip Abd Hip ER Hip ABD Hip ER

Hip

To

rqu

e(%

BW

*m)

Hip Strength PRE

POST

Trainers

*

*

Controls

Uninjured females with proximal mechanism

6-week intensive hip strengthening program

Last 4 weeks: functional strength training

Willy and Davis, 2011

Does strength training alter mechanics? Willy & Davis, 2011

Hip adduction Hip Internal Rot Pelvic drop

PRE POST

-5

0

5

10

15

20

25

1 51

% Stance

De

gre

es

(+) HADD

-12

-7

-2

3

8

13

18

1 51

% Stance

De

gre

es

(+) HIR

-15

-10

-5

0

5

10

15

1 51

De

gre

es

% Stance

(-) CPD

Willy and Davis, 2011

Pre-strengthening Post-strengthening

Wouters 2012, Snyder 2010, Bennell 2010

Single leg squat Willy and Davis 2011

0

2

4

6

8

10

12

14

HADD HIR CPD HADD HIR CPD

Deg

rees

Single Leg Squatting Kinematics Pre Post

**

Trainers Controls

*

Willy and Davis, 2011

All performed with mirror feedback

Skill failed to transfer to running

Gait retraining: Female runners with PFPReal time or mirror feedback

Noehren 2010, Willy 2012 & 2013

PRE Training 3 Months

Real time feedback Noehren 2010

Mirror feedback Willy 2012 & 2013

8-sessions

Cued: reduction in medial collapse

Age (yrs) km/wk Duration of PFPS (yrs)

22.1 ±1.5 23.7 ±11.3 4.3 yrs ±2.5

Results: Demographics and subjective data

Willy et al. 2012

Step 1: train the movement in walking

http://www.yawcam.com/

Software to stream webcam

Markers placed on outside of knees

Cue:

“Push marker toward

walls”

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Cue:

“Push marker toward

walls”

Markers placed on outside of knees

Step 2: Train the movement in runningMedial collapse

Cue: “Keep the markers level”

PostBaseline

Incorporating mirror gait retraining into practice:Option 1: Active runner

Adapted from: Willy RW, Scholz J, and Davis IS. 2012

Breakdown of retraining scheduleWeek 1 Week 2 Totals:

Retraining

Session1 2 3 4 5 6 7 8

Running

Time (min)15 18 21 24 27 30 30 30

195 running

min

Feedback

Time (min)15 18 21 24 21 15 9 3 126 FB min

Typical profile

1. Patellofemoral pain, ITBS

2. Presently running 15 min

3. ≤4/10 VAS pain

4. Can self-correct a SLS

Injuries associated with overstriding

Most Common Running Injuries

% Running Injuries

Female/Male

Patellofemoral Pain 22% 62%

Iliotibial Band Syndrome

11% 62%

Plantar Fasciopathy 10% 46%

Tibial Stress Injuries 7% 57%

Achilles Tendinopathy

10% 42%

Patellar Tendinopathy

10% 43%

Taunton, 2002

Runner 1: Recurrent tibial stress fracturesRunner 1 Runner 2

Runner 2: 66.8 bw/sec

IVLR:

Runner 1: 107.2 bw/sec

Predictors of impact forces:

-Lower leg angle

-Peak knee flexion

-Footstrike distance from COM

Willson 2014, Wille 2014

Runner 3: Left patellofemoral painRunner 3Runner 2

Predictors of PFJ loads

-Step length

-Lower leg angle

-COM oscillation

-Peak knee flexion

-Footstrike distance from COMWillson 2014, Wille 2014, Lenhart 2014

Patellofemoral joint stress

PF

J S

tress (

mP

a)

% Stance

Runner 2:

6.0 mPa

Runner 3:

8.3 mPa

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Influence of step length on hip adduction

Hip adduction increases with longer step length Heiderscheit 2011

Decreases firing of the gluteal musculature prior to footstrike Chumanov 2012

Increases demand on hip musculature during loading Lenhart 2014

Case Study 1:

Recurrent tibial stress fractures

Impact forces

Fo

rce (

bw

’s)

Stance (ms)

Classification: Overstriding and dynamic valgus mechanics

103.0 bw/sec

Willy 2016

Run 1: Continuous feedback on a treadmill

Run 2-8: Self-controlled Feedback outdoors

Fixed

Practice

Variable

Practice

Incorporating step rate retraining into clinic:

Cue an increase of 5-10% in step rateWilly SJMSS 2016

Various apps:

Prometronome

Runcadence

runcadence

Case Study, cont’d: Impact forcesPRE 1MO

Impact forces

PRE: 107.2 bw/sec

1MO: 67.9 bw/sec

Impact forces

Fo

rce (

bw

’s)

Stance (ms)

Step rate

PRE: 168 steps/min

1MO: 181 steps/min+7.2% -34.1%

Case Study, cont’d: Peak hip adduction

PRE 1MO

0

2

4

6

8

10

12

14

16

0 20 40 60 80 100

PRE

Peak hip adduction

3.8 degree reduction

(+) ADD

Deg

rees

% Stance

Hip Add Post-Rehab Load CapacityUninjured Load Capacity

Envelope of functionDye 2005

Figures courtesy of Tom Goom, BSc (Hons), MCS

www.running-physio.com

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Cumulative

loads

Peak loads Rate of

loading

Willy and Meira, IJSPT, 2016

Recreational runners: Karsten

et al., IJSPP, May 2015

Randomized into endurance-

only or endurance+strength

training:

6 weeks, 2x per week, 4 sets of

4 reps, 80% 1-RM: Romanian dead lift

Squat

Calf raises

Lunges

5-k performance: 45 sec± 24

faster 5k for strength trainers,

no change for endurance-only

group

Highly trained runners:

Meta-analysis of 5 articles: 2-

3x/week, 8-12 wks: Large

effect on running economy: -

1.42 (-2.23- -0.60 95% CI) Balsalobre-

Fernadez 2015

Effect of strength

training on

performance

Is strength training effective to reduce

“overuse” injuries? Lauersen 2014

Massive Meta-analysis: 26,610 subjects, 3464 injuries

Strength training?

Proprioceptive training?

Stretching?

Strength and/or Proprioception training:

Almost halved the risk of overuse injury

No effect on injury risk!

Willy and Meira 2016

Achilles tendon moment arm= 0.037 meters Manal 2013

Single leg squat : External DF moment= 1.5 Nm/kg Flanagan 2005

Assume mass of runner= 75 kg

= 4.1 body weights of Achilles tendon force for single

leg heel raise without weight

Achilles Tendon Force Running 5’44”/km

Return to running programs?

• Peak loads: Heavy strength training

• Rate of loading: Plyometrics

• Cumulative loads: Return to running

programs

Should be walking >7500 steps/day

before initiating Willy and Meira 2016

Will the real load parameter step forward?Nielsen et al., 2013, Edwards 2010, Miller 2014

Plantar fasciopathy

Achilles tendinopathy

Gastrocnemius injuries

Patellofemoral pain

Tibial stress injuries

Degenerative knee issues (OA)

Peak loads

Cumulative loads

Susceptible

to

incre

ases i

n s

peed

work

Susceptible to increases in

running volume

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7

X-Train options: walking, cycling, elliptical, nordic skiing

Perform strength training on running days

Summary

• Runners get injured: Multifactorial

• Strengthening doesn’t change movement patterns

– Peak load tolerance

– Improves running economy

• Retraining necessary to change movement patterns

• Plyometrics: Rate of loading

• Return to running program: Cumulative loads

Acknowledgements

and contact information

Simon Robitaille, PHT, FCAMPT & Association Contact Physio

Stacey Meardon, PT, PhD; John Willson, PT, PhD

Graduate assistants & Research participants

Contact information

Twitter: @rwilly2003 Email: willyr@ecu.edu