Running Mechanics Part II: Top 5 Mechanical Faults

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Top 5 Mechanical Running Faults

In my last post we discussed some running gait pattern norms. Once again, it is difficult to completely standardize running gait however researchers have been able to set a range of “optimal” angles and loads through extensive observation on runners with and without pain.  So now we know that anything deviates TOO MUCH from the closest thing to a standard can produce future problems.  For clinicians who want to analyze gait a few recommendation for you would be: educate yourself on running gait normal and abnormal patterns, and strongly consider observing running gait in slow motion or use some of gait analysis system. It is really difficult to see under the naked eye unless you have observed thousands of runners and actually paid attention to mechanics. 

Recall what I stated in the first post, “in order to run the athlete has be able to properly absorb shock, demonstrates proper alignment of the lower quarter joint and demonstrates good stability of the trunk, pelvis, knee, and ankle”. Or as I put it “YOU HAVE TO BE FIT TO RUN.” 

When analyzing running gait, crucial deviation or faults will be seen during initial contact through all the way through toe off (the period of time one foot is on the ground). With that being said, lets look at the top 5 common running mechanical deviations.  This may be helpful to some runners and clinicians who are trying to figure out why the athlete may be experiencing pain. 

Some of these faults can occur together. Some runners exhibit 1 or 2 deviation, some more than that. We must remember that the lower quarter is connected chain. What happens at the hip can affect the knee and foot and vice versa.  If there is a weak link at either the hip or foot, or both, I can bet money that you may see some faulty movement especially the longer the run (because fatigue will settle in).

 Powers et al- lecture 2018- Movement Performance Institure

Powers et al- lecture 2018- Movement Performance Institure

1.   Limited Knee Flexion During Max Loading

During the mid support phase of running gait you ideally want to observe 30-40 degrees of knee flexion.  Power et al. observe that in runners that demonstrates <30 degrees of knee flexion (running on a straight knee) reported knee pain and ground reaction forces resulted to be much higher than seen in runners that demonstrates >30 degrees knee flexion. 

Landing on a flexed knee helps absorb the weight of the body hitting the ground, the straighter the knee the harder the landing the less absorption by the knee and hip take place. 

Why does this happen? First thing you may need to address is possible quadriceps weakness! In order for the knee to flex during loading the quadriceps needs sufficient ECCENTRIC strength. 

 2.   The Hip Drop

I analyze running gait every day during my runs, and this is one of the most common things I see, especially in females more so than males. Ideally you don’t want to see much hip drop. The peak amount of drop desired ranges from 5-10 degrees (4). If you can see a hip drop with the naked eye- that already is too much of a hip drop. The problem with the hip drop is that since the lower limb works as a whole unit- hip drop promotes medial knee collapse and sometimes increase midfoot pronation. Many studies have shown that the runners that exhibit patellofemoral joint pain tend to demonstrate larger  amounts of hip drop. Excessive hip drop contributes to spikes in knee joint compression, low back joint compression, and increase back paraspinal activity.  

Therefore runners who display a hip drop may complain of back back, knee pain, hip pain, shin splints, or ITB pain. 

Causes:  

·     weak Gluteus Medius and Maximus. Your glute maximus is the only triplanar muscle, meaning: it helps extend your thigh, bring your thigh out to the side, and externally rotate your thigh. 

·     ITB stiffness : can pull your thigh inward and promote hip drop.

·     Posterior tibialis weakness ( the foot can affect the hip remember)

How to correct

·     Strengthen your glutes!

·     Gait retraining, run in front of mirror and don’t allow your hip to drop (3,6).

 

3.   Knee Valgus

 Chris Powers lecture 2018- Movement Performance Institute

Chris Powers lecture 2018- Movement Performance Institute

Like I mentioned above the hip does affect the knee. When the pelvis drops it does shift the center of mass more towards the center causing excessive internal rotation of the thigh (2) thus creating a knee valgus angle. Since it tends to be common that the glutes will test out as weak, of course the compensation has to come from somewhere, and so therefore the quads become very dominant.  

The movement impairment of the knee valgus associated with the pelvic drop and over dominant quadriceps is what commonly causes knee pain, or the commonly heard diagnoses’ of: patellofemoral joint pain syndrome, and patellar tendinitis/runners knee. 

Causes:

·     Weak hip external rotators and abductors (GLUTES)

·     Sometimes some runners may have relatively strong glutes but may be just have a coordination problem. I have had some runners practice in front of the mirror and have them try to NOT let their knees drive in and they can correct it just by paying attention. 

Correction:

·     work on glute strengthening, ( clam, sidelying hip abduction, sidesteps) and pay attention to avoiding the knee from diving in. 

4.   Foot pronation

 Loading phase:  Right foot: midfoot pronated and foot externally rotated, vs the left foot . History of posterior tibialis tendonitis on the Right Foot.

Loading phase:

Right foot: midfoot pronated and foot externally rotated, vs the left foot . History of posterior tibialis tendonitis on the Right Foot.

Foot pronation is when the midfoot drops towards the ground especially during the loading phases. The foot is meant to be strong but also flexible, therefore some degree of midfoot pronation is expected, however the problem is when there is an excessive amount of midfoot pronation.  The peak amount of pronation desired during the loading phase of running gait is 10-15 degrees (1).  Some researchers state that shoes provoke an increase in pronation, while others solely believe that weakness is the main factor, and many others believe it is more multifactorial. 

This means that foot pronation can be caused by : 

·     stiffness of the ankle causing compensation via midfoot pronation in order to get the foot to roll over the forefoot

·     pelvic drop causes a kinetic chain fault, forcing  lower leg ( tibia) to externally rotate and therefore cause the midfoot to drop. 

·     weakness of the tibialis posterior, which helps support  the midfoot.

Correction:

·     correct the hip drop if you exhibit one

·     Make sure you have full ankle mobility : 20 deg of ankle dorsiflexion

·     Work on posterior tibialis strengthening exercises ( see previous blog for exercise tips) and try to push off big toe versus outside of foot. 

 

5.   Erect posture

Ever notice some knee or back soreness after a long or even fast run?  Well you may be running with your trunk a little to stiff and straight.  When you don’t slightly bend forward , you change the center of gravity back towards your hips and therefore force your body refrains from using the glutes and instead recruits the quadricep. This leads to lack of the needed TRIPLE EXTENSION during toe off. Triple extension is when the ankle pushes off, knee and hip extends via their associated extensor musles. In a study by Powers et al, researchers found that a trunk lean of 10 degrees led to a reduction in the peak patellofemoral joint stress by 13% (5). 

 Causes:

·     Calf weakness

·     Tight hip flexors- can cause and anterior pelvic tilt, so to avoid flexing your hips too much, some runners will stay up tall. 

·     Glute weakness

Correction:

·     Try to lean forward SLIGHTLY  when you are running, pick a recovery/slow run when you first attempt this. 

·     Strengthen core , glutes, and gastrocs

·     Stretch your hips. 

 

 

Quick 2 cents: Runners there is a saying, “if it aint broke dont fix it” , HOWEVER OPTIMIZING movements, strength, and mobility is BENEFICIAL!

TRAIN SMART AND RUN WELL.

Jessica Mena PT, DPT, OCS, CSCS

Doctor of Physical Therapy

Board Certified Orthopaedic Clinical Specialist

RUNNER

 REFERENCES

1. Byl, N., Davis. I., Heiderscheit B., Powers. C. 2013 Research Symposium- The Science of Running,2013. CPTA Nov 9-10.

2. Dierks T. A., Manal, K., Hamill J. Davis I.S. Proximal and Distal Influences on Hip and Knee Kinematics in Runners with Patellofemoral Pain During a Prolonged Run.  Journal of Sports and Orthopaedic Physical Therapy. 2008 38 (8) 

3. Heiserscheit, B. Gait Retrainig for Runners- In Search of Ideal. Journal of Sports and Orthopeadic Physical Therapy. 2011. 41 (12)

4. Powers, C. The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective. Journal of Sports and Orthopaedic Physical Therapy. 2010 40:2

5. Teng, H-L., Powers, C. Sagittal Plane Trunk Posture Influences Patellofemoral Joint Stress During Running.  Journal of Sports and Orthopaedic Physical Therapy. 2014. 44 (10) 785-792

6. Nakagawas, T.H., Maciel, C.D., Serrao F.V. Trunk Biomechanics and its association with hip and knee kinematics in patients with or without patellofemoral pain. Journal of Manual Therapy. 2015 20: 189-193 www.elsevier.com/math

 7. Willy, R. W.., Scholz J.P., Davis I.S.  Mirror Gait Retraining for the Treatment of Patellofemoral Pain in female Runners. Clinical Biomechanics. 2012 (27) 1045-1051

Running Mechanics: The Introduction

 Photo Credit:  New Basin Blues

Photo Credit: New Basin Blues

With 36 million people running in the United states, running has become a big area of study. When it comes to running gait (running much like walking) it will vary from runner to runner according to specific muscle imbalances. For this reason, it is difficult to standardize the “Perfect Form”  however there is research to support what “normal” running should closely resemble.  Why is this important? It is important because within the running community there is an incident of injuries as high at 79%, most occurring at the knee. Therefore, you have to think along the lines that these athlete run hundreds of miles a year, there is a repetitive stress, and the ones that are injured may be moving sub-optimally.  The purpose of this post is to introduce basic running mechanics so that we can further analyze gait in the next post. 

 

Running is sport that requires repetitive impact and push off . Each time the foot hits the ground the foot, knee, and hip have to withstand and tolerate a ground reaction force 2-3 of our body weight (5).  The demand is VERY HIGH, therefore before I even get started I want to make this statement as clear as possible : YOU HAVE TO BE FIT TO RUN, at least run with less probable cause of injury. 

 

There are major 2 phases of running, and they are the stance phase which makes up about 30% of gait, and the swing phase which makes up 70% of gait. The faster we run, the shorter the stance phase becomes (3).

 

The stance phase is the period in which the foot makes contact with the running surface and this phase is made up of 3 components: foot strike, mid support and toe off. 

Stance Phase: 

A: Foot strike

This marks the beginning of the stance phase, it occurs when the foot first makes contact with the ground.  Lets imagine that both feet are floating off the ground and you are about to land with one leg, that initial second you touch the ground is foot strike. 

There are 3 ways runners strike the ground, and that is with either their heel  (heel-strike) the middle of the foot (mid-foot strike) or with the balls of the feet (Forefoot strike) (2). About 75% of runners land with their heel, 25% with the midfoot and forefoot (5). 

The major differences between the two striking patterns is that heel strikers land in more dorsiflexion (ankle flexion) and research demonstrates that ground reaction forces are more evenly distributed into the ankle and knee. Is has been shown in some studies that heel strikers tend to absorb shock better than forefoot strikers- mostly because there is an increase in hip and knee flexion which acts as a spring.  Their counterparts land in plantarflexion (ankle pointing/extension) and most energy absorption at foot contact is absorbed at the ankle. 

 

What should we see at foot strike? 

In this phase the fundamental goal is optimal energy absorption throughout the lower quarter.

Angles to look for at foot strike are centered at the hip and knee.

Hip: >25 degrees of hip flexion

Knee: 30-40 Degree Knee flexion

 Photo: From Powers et al- Movement Performance Institute

Photo: From Powers et al- Movement Performance Institute

 

The stiffer a runner lands in will lead to an increase in unnecessary stress at the hip and knee joints. 

The  peak Muscle activity seen during this phase are as follows: 

·     Posterior tibialis: because this muscle will help control pronation of the midfoot as it loads

·     Peroneals: controls midfoot especially with those than land with the midfoot

·     Glutes: as they are suppose to stabilize the hip/knee. 

·     Quads as they assist in eccentric load during knee flexion 

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B: Mid Support

The start of the mid support phase of stance begins when the whole foot makes FULL contact with the ground and end right when it begins to roll over the toes. 

This is a critical part of the stance phase because this is where the body will need maximal pelvic, knee, and ankle stability. 

 

What should we see at mid support? 

This is where we will see the biggest deviations! This is the frame we should all pay attention do when doing running gait analysis. 

Optimal joint angles:

Hip Flexion: >25 degrees

 Powers et al: Movement Performance Institute (L picture faulty; R- optimal )

Powers et al: Movement Performance Institute (L picture faulty; R- optimal )

Knee Flexion: 40 degrees

Forward Trunk lean: 10 degrees

Lateral trunk lean: <5 degrees

Knee valgus of Varus <5 degrees

Pelvic Drop < 5 degrees

Minimal anterior pelvic tilt

Limited foot pronation

Knee in line with toe

Foot not crossing midline

The Peak muscle activity seen during this phase are as follows: 

·     Gastroc, peroneals, posterior tibialis: as they control the drop of the forefoot onto the ground

·     Glutes: as they are to stabilize the hip, during this phase we see many faults such as the hip drop if the glutes are not strong enough to support and stabilize the pelvis. 

·     Quadriceps: as they eccentrically support the knee and allow for proper shock attenuation through knee flexion

Faults seen: 

-       Excessive midfoot pronation

-       Excessive Hip drop

-       Knee diving in (valgus) or out too much (Varum) 

-       Trunk too erect

-       Trunk leans too much to one side

-       Foot crossing midline 

-       Knee past the foot 

Injuries from these faults just lead to increase shock which can lead to injuries such as knee, hip, low bac, ankle pain- Achilles tendonitis, plantar fasciitis, patellar tendonitis, stress fractures. 

 

C: Toe Off

During toe off phase the heel lifts off the ground and the toes begin to leave the ground. Here the glutes and calves should provide little power for push off. It is what I call the “going along for the ride” phase.

Here we should see about 10 degrees of hip extension.

In the runners with stiff hip flexors we may see faults as excessive low back extension, or rotations of the pelvis. 

As the toes leaave the ground we move into the swing phase. 

SWING PHASE

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The swing phase begins once the toes leave the ground and ends when the foot is about to strike the ground again. 

The swing phase in made up of 3 smaller components: the follow through, the forward swing, and foot descent.

 

D: FOLLOW THROUGH

During the follow through phase of swing, the foot leaves the ground up until right before the knee begins to move forward. 

The peak muscle activity is seen in the:

·     Quadriceps: as they help control how much the knee bends 

·     Hamstrings as they help bend the knee

·     Hip flexors: as they help control and limit hip extension and assist with flexing the hip to allow the leg to come forward.

Faults:  Hip drop, inner thigh (femoral) coming towards the center 

 

E. Forward Swing

In the forward swing phase the leg moves forward and knee begins to straighten out and reach out in front, and transitions into the foot descent phase.

During this phase the hip and knee bend forward which help propel the body forward. 

The peak muscle activity seen in the following: 

·     Anterior Tibialis: as they help clear the foot from the ground

·     Hip flexors: help flex the hip up 

·     Hamstrings: as they help control hip flexion eccentrically

F: Foot Descent

 During this last phase of swing, both legs are gloating off the ground and the foot is traveling back down towards the ground. You will begin to see knee extension as the leg reaches down. 

The peak muscle activity is seen in the: 

·     Anterior tibialis: as it helps eccentrically control plantar flexion (toes pointing down_

·     Quadriceps: as they help extend (straighten) the knee

·     Hamstrings: as they assist and help control knee extension, as well and begin to extend the hip as the leg drops down towards the ground. 

 

We can’t exclude the upper body when talking about running gait because it does play a big role. The arms swing in order to counter balance the leg movement and help balance the trunk as well (3) It must be said that in order for the hips and legs to move through the cycles, it does require a relatively strong and stable trunk . A strong and stable core helps absorb impact forces. Remember that our pelvis and legs attach to the trunk, so if your base is not stable, then you cant expect your lower quarter to work as efficient. 

 

 

 

References

1. Byl, N., Davis. I., Heiderscheit B., Powers. C. 2013 Research Symposium- The Science of Running,2013. CPTA Nov 9-10. 

2. Davis, I., Rice. H.M., Wearing S.C. Why Forefoot Striking In Minimal Shoes Might positively Change the Couse of Running Injuries.  Journal of Sports and Health Science. 2017. 1/9

3. Nicola, T. Jewison D. The Anatomy and Biomechanics of Running.  Clinics in Sports Medicine31 (2). 187-201 , April 2012. https://www.researchgate.net/publication/221838595_The_Anatomy_and_Biomechanics_of_Running

4. Novacheck T.F. Biomechanics of Running. Gait and Posture. 1998 77-95

5. Powers, C. The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective. Journal of Orthopaedic and Sports Physical Therapy. 2010. 40:2  http://movementpi.com/wp-content/themes/movement_pi/publications/Hip_mechanics_and_knee_pain.pdf

6. Souza R, Powers C. Differences in Hip Kinematics, Muscle Strength, and Muscle Activation Between Subjects with and without Patellofemoral Pain. Journal of Orthopaedic and Sports Physical Therapy. 2009 39:1 http://movementpi.com/wp-content/themes/movement_pi/publications/Hip_strength_and_motion_in_patellofemoral_pain.pdf

 

 

 

Meniscus Injuries: What That Means, and What To Do Next.

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There are many injuries that forced athletes out of training or competition, some injuries more than others. An injury that can become problematic over time are meniscus tears. It is well known that the knees are a common site of injury in all sports, and overall the American Academy of Orthopedic Surgeons estimate that they perform 850,000 meniscectomies per year (1). 

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The menisci are fibrocartilaginous structures located in the knee joint. These wedge shaped structures play an important role in knee joint stability and biomechanics, they transmit anywhere from 50-90% of compressive forces depending on the angle of the knee joint. The menisci are our shock absorbers, they endure compressive, shearing, tensile forces on a daily basis. Therefore, the more active you are the more stress these structures encounter, the more degeneration they will undergo and in some cases may suffer from small to large tears. 

 The lateral meniscus is O-shaped while the medial meniscus is more C-shaped and unfortunately the whole structure is not well vascularized. The periphery of the menisci receive the most blood supply while the most central portion receive none. Due to this, tears that extend into the inner portion of the menisci have a very difficult time healing and therefore tend to not be repaired.

Most meniscus injuries involve the medial meniscus mostly because it is more fixed, it attaches to the joint capsule and medial collateral ligament of the knee (MCL).

A recent study specifically looked at the rate of meniscus injury in long distance runner and found that there was a slightly higher occurrence of meniscal lesions in higher trained runners vs lower trained runners (7), which has deduced to be to higher loads and increases in repetitive stresses. Most runners who suffer from a meniscus injury will be considered a "degenerative meniscus tear/injury." Acute tears in runners will most often be seen in trail runners where they have landed on a rock wrong and twist their knee,  track runners who have been tripped on the track, or hurdlers who have landed wrong.  

Mechanism of Injury

A majority of articular cartilage lesions result from trauma or repetitive minor trauma. In most cases a tear occurs a s a result of twisting the knee while the foot is planted (there is load on the leg). This can occur with a sudden turn or change in direction. 

 According to research the risk factors to developing acute meniscal tears are (6):

1.    Sports: soccer, rubgy, running

2.    Weight bearing during trauma 

3.    Increased BMI 

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The most common tears are vertical longitudinal, oblique, degenerative, and radial, and horizontal. 

 

Signs and Symptoms: 

1.    Pain with bending, walking, exercising on the inside or outside of the knee

2.    Swelling

3.    Locking (if the tear is severe enough)

4.    Catching

5.    Clicking that is painful 

 

Management: 

What guides medical professionals to the intervention is based on symptoms severity, disability, and extent of injury. 

Indications for a meniscus repair are as follows:

1.    Meniscus tear with tibiofemoral joint line pain

2.    Patients younger than 50 y.o , or >50 but athletically active

3.    Concurrent knee ligament reconstruction 

4.    Reducible meniscal tear, good tissue integrity, normal joint like position post surgery

5.    Peripheral single longitudinal tear 

6.    Middle third region tear with some vascularity

If surgery in contra- indicated conservative treatment is sought after, which consist of pain management and physical therapy. The rehabilitation program consist of:

1.    Normalizing knee active and passive range of motion.

2.    Normalization muscle imbalance of the muscle above and below the knee joint

3.    Improving movement impairments 

4.    Steady progression of strength and function. 

Meniscus injury outcomes : 

For the individuals and undergo surgery about 80% of athletes will return to original sport (5). According to the literature the athletes who are under 40 y.o, have suffered an acute and painful tear  and have symptoms of locking and catching have a success rate of 8% to return to sport after surgery.  For the individuals suffering from degenerative meniscal injuries conservative treatment is always considered first. Surgery for degenerative meniscal injuries have a low success rate of 50% return to sport. 

My personal thought on meniscus tears is: 

1. If there was a trauma and injured your knee,  you can't play your sport and its a an acutely diagnoses meniscus tear- repair it, rehab, and get back out there.

2. If not: REHAB, CHANGE THE WAY YOU MOVE, OPTIMIZE MUSCLE FUNCTION, BE PATIENT AND YOU WILL GET BACK. 

 

TRAIN SMART

JESSICA MENA PT, DPT, OCS, CSCS

Doctor of Physical Therapy

Board Certified Orthopedic Clinical Specialist 

Certified Strength and Conditioning Specialist

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References:

1.    Baumgarted B. To Run or Not to Run: A Post-Menisectomy Qualitative Risk Analysis Model for Osteoarthritis When Considering a Return to Recreational Running. Journal of Manual Therapy. 2007. 15(1) 

2.    Cavanaugh JT, Killian SE. Rehabilitation Following Meniscal Repair. Current Rev. Musculoskeletal Medicine. 2012 5(1). 

3.    Gray JC. Neural and Vascular Anatomy of the Menisci of the Human Knee. Journal of Orthopaedic and Sports Physical Therapy.  1999 29. (1). 

4.    Logerstedt DS, Scalzitti DA, Bennell KL, Hinman RS, Granelli HS, Ebert J, Hambly K, Carey JL, Mackler LS, Axe MJ, McDonough CM. Knee Pain and Mobility: Meniscal and Asticular Cartilage Lesions Revision 2018. Clinical Practice Guidelines. 

5.    Nakayama H, Kanto R, Kambara S, Kurosaka K, Onishi S, Yoshiya S, Yamaguchi M. Clinical outcome of the meniscus repairfor isolated meniscus tear in athletes. Asia-Pacific Journal of Sports Medicine, Arthroscopy, Rehabilitation Technology. 2017 10(4)

6.    Snoeker BA, Bakeer EW, Kegel CA, Lucas C. Risk Factors for Meniscal Tears: A Systematic Review Including Meta- Analysis. Journal of Orthopaedic and Sports Physical Therapy. 2013. 43(6). 

7.    Weidekamm-Schueller C. Schueller G, Uffman M, Basder T. Incidence of Chronic Knee Lesions in Long-Distance Runners based on training level: Findings at MRI. European Journal of Radiology. 2006. (58). 

Stress Fractures

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As running become more popular as a form of exercise, the risk for developing musculoskeletal injuries goes up as well. Stress fractures are one of the most serious injuries, it account for 6-20% of injuries in track and field athletes and long distance runners (4) . In runners, stress fracture are most commonly seen in the tibia, which requires an average of 8 weeks of recovery (2). The focus of the post will be in educating you on what stress fractures are, the risk factors, and preventative suggestions. 

What's a Stress Fracture? 

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Before we go into details about stress fractures, lets talk about something we all learned in High school, Wolff’s Law. Wolff’s law was developed by a German surgeon that states “bone in a healthy person or animal will adapt to the loads under which it is placed. If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading. The internal architecture of the trabecular undergoes adaptive changes, followed by secondary changes to the external cortical portion of the bone.”Therefore, if the stress occurs too fast without recovery, athletes develop microfractures.  

Most stress fractures occur in the cortical bone (1). Cortical bone is located “in the diaphysis of long bones and the shell of square bones.

Stress fractures are tiny microfractures of the bone and with running tend to occur from repetitive stress.  There are 2 types of fractures, fatigue fracture and insufficiency fractures. Fatigue fractures are stress fractures that affect the cortical bone due to over-stress (2). Insufficiency fractures are caused by low bone mineral density (seen in anorexic runners, runners with osteoporosis, osteopenia). With proper recovery time, the bone damage is repaired. 

HOWEVER, the problem develops when an athlete maintains an excessive running volume and inadequate recovery time  because this can lead to BONE WEAKNESS and STRESS FRACTURES. Stress fractures tend to occur in the first month of training or when training is increased too quickly. 

Risk Factors for Developing Stress Fractures: 

Definitely describing the factors that lead to stress fracture can be difficult because there are an array of variables that play into the problem . There are many intrinsic and extrinsic factors that lead to stress fractures. 

Intrinsic factors: 

1.    Increase in impact forces: research has shown that athletes who demonstrate increase vertical load sustain stress fractures more so to runner that do not demonstrates that. So the next question becomes, how to runners average higher vertical loads vs lower vertical loads?  That answer is: fatigue. At the end of fatiguing runs, ground reaction forces (GRF) as observed to be greater in those runners with a history of stress fractures. It is noted that muscle fatigue alters running biomechanics which is associated with a 25% increase in GFR (2). 

2.    Poor strength : This plays off the previous factor. Decrease strength as well and endurance of the muscle that support the hips and lower extremities such as the glutes, gastocs, and ankle stabilizers (peroneal, posterior tib) all contribute to balance and power us through our work outs. There will be imbalances and  strength discrepancies and all that leads to is compensation and injury. I have said this hundreds of times and I will say it again, YOU NEED TO BE STRONG IN ORDER TO RUN.  Strength training is crucial! 

 Pronation is NORMAL- however not coming out of pronation, or too much of it is problematic&nbsp;

Pronation is NORMAL- however not coming out of pronation, or too much of it is problematic 

3.    Excessive hip adduction and rear-foot eversion: faulty running mechanics means, decrease shock absorption or excessive force in certain joints of the body. Too much hip adduction (leg landing towards midline versus under hip) causes increase stresses at the knee and lead for the foot to compensate by landing on the outside of the heel leading to increase pronation arc and therefore creating more stress at the ankle joint. 

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Extrinsic Factors: 

1.    Increase in frequency, duration, or intensity when the athlete is not ready: this tends to be a very common trend in more athletes who suffer from stress fracture. Somewhere in training things progressed too fast. 

2.    Running on harder surfaces vs soft – studies have shown that running on the treadmill decrease GRF versus concrete. 

3.    Failure to schedule rest days after higher intensity runs : REST DAYS ARE NEEDED. It is really easy for runners to get caught up in training and the desire to progress. However, the body needs to recover and heal. Overtraining without breaks leads to opposite of what athlete want, and that breakdown, injuries, and decrease performance. 

4.    Poor periodization training: Proper periodization blocks of 4-6 weeks of progressive base building and progression of 10% of miles per week is overlooked or ignored by many. Set a plan, follow the plan, and don’t get too excited. 

5.    Training in old shoes: some studies have looked at show breakdown, many coaches and companies say max of 300 milers her shoe. However that can vary depending on your weight, miles per day etc. I say if the shoe doesn’t feel supportive, there is wear and tear of the sole, get new shoes. Another good recommendation is have a difference pair of shoes for cross training, speed workouts, and long distance runs. 

Signs and Symptoms: 

1.    Insidious onset of pain that develops towards the end of a run, that then progresses to pain early on with running is the athlete continued to train. 

2.    If the fracture advances, the athlete will feel pain even with non running related activities and will have pain with regular ambulation/walking. 

3.    Focal bony tenderness or sharpness with weight bearing and swelling, will feel like really bad shin splints. 

4.  Sometimes: discoloration/bruising. 

 

Some questions to ask yourself if you believe you may have a stress fracture and need to get checked out. 

a.    Has your training changed? If so, how much have you increased your miles per week, or have you increased your pace? and if so by what? 

b.    Are you waking up with more aches? 

c.    Are you taking rest days? 

d.    Have you changed your shoes, or started running in new shoes? 

e.    Is the pain getting worse?

f.     Does walking produce your pain? 

g.    Is the pain limiting your ability to train?

If yes >4 , go to the doctors, or get checked my a physical therapist. Stress fractures can present as shin splints, or tendonitis. Only way to verify a fracture is through imaging, and even then they sometimes will not show up on X-ray until 1-2 weeks later. 

 Lift some iron!!!

Lift some iron!!!

Prevention Interventions: 

1.    Strength Training: ALL runners and athletes greatly benefit from increases in strength. For runners specifically they need hypertrophy, and muscle endurance. 2-3x per week with increases in load up to 75-95% of 1RM. Progression should be made in 3x3 week  periodization blocks. If you are not sure what that means, start by lifting some light weights and slowly progress and get yourself a trainer. Incorporate loaded squats, lunges, step ups, core and glute exercises. 

Screen Shot 2018-05-29 at 11.38.19 AM.png

2.    Do not increase miles by more than 10%. Increase 10% for 3 weeks and on the fourth week should be an easy week, and resume back to training. For beginners, running 3x a weeks is good, intermediate and elite runners need to play close attention to aches and pains post hard work outs and take days off seriously. 

3.    Own more than 1 pair of shoes. You should have a pair for cross training, speed days, and distance running.

4.    TAKE 1 REST DAY A WEEK: that means very light 30 min or less JOG, walk, or so nothing and stretch. 

 

 

LISTEN TO YOUR BODY.

TRAINING SMART, will allow your run better, faster, stronger, and injury free

 

- JESSICA MENA PT, DPT, CSCS

and fellow runner. 

 

 

 

 

 

References

1.    Harrast MA, Colonno D. Stress Fractures in Runners. Clinical Sports Medicine 2010. 29. p399-416. doi:10.1016/j.csm.2010.03.001 

2.    Magness S, Ambegankar JP, Jones MT, Caswell D. Lower Extremity Stress Fractures in Runners: Risk Factors and Prevention. Injury Prevention & Performance Enhancement- Human Kinetics. 2011. Pp 11-15

3.    Magrum E, Wilder RP. Evaluation of Injured Runner.  Clinical Sports Medicine. 2010 p 331-345. Doi: 10.1016/j/.csm.2010.03.009

4.    Meardon SA, Willson JD, Gries SR, Kernozek TW, Derrick TR. Bone stress in runners with tibial stress fracture. Clinical Biomechanics. 2015 

5.    Nicola T, Jewison D. The Anatomy and Biomechanics of Running. Clinical Sports Medicine. 2012. 187–201 doi:10.1016/j.csm.2011.10.001 

Ankle Sprains Part II: Getting Back to Running

In Part I of the ankle sprain blog, we went over some basic anatomy, types of ankle sprains, causes, and acute treatment. Now in Part II we will focus on the post acute phase. Research has shown that exercise therapy is an essential element to treatment ankle sprains. Therefore, my goal is to illustrate to you some components to focus after you have surpassed the acute phase of your injury. The focal point will be centered on working towards getting you back to running!

Keep in mind that everyones rehabilitation will vary, what I present here is more of a very basic outline, as I have said before for grade III sprains go get checked by a medical professional just to rule out any other possible structural involvements.

Now lets get started. 

1.     How long does the healing process take?

In regards to ligament tissue healing times, the length will depend once again on the grade of the sprains. ( see part I for explanation of each grade)

Grade 1 ligament sprains take about 0-3 days to heal

Grade 2: 3 weeks – 6 months

Grade 3: 5 week – 12 months. 

Remember that in Grade II and III sprains you are also experiencing some discomfort and soreness from the surrounding ankle muscles. Therefore, when it comes to rehabilitating from a sprain, yes, the focus is on allowing the ligament to heal, but you are normalizing the injured surrounding muscles.  

We really can’t physiologically speed things up, but we sure can protect and promote healing by doing the right things.

2.     You have been working on the swelling and range of motion. What should you focus on next? 

Progression timelines will vary depending on the grade of sprain and of course the individual. Meaning someone who experienced a grade I sprain may be able to progress to exercises after day 3, where is grades II and III, that day may be moved back to day 7 or 8.  For Grade II-III ankle sprains expect the acute inflammatory phase to last up to 7 days post injury. Ligaments will be at their weakest during healing process anywhere from day 5 to day 21 post injury. I know that this is a very wide timeframe, but once again all this means if you have to be careful to no progress any exercises too quickly.

Some factors that should be taken into consideration before progressing to strengthening and balance exercises are: 

1. Has the pain has significantly decreased? 

2. Have you been able to manage the swelling and stiffness?

3. Have you been working on range of motion with noted improvements?

4. Can you weight bear on the inured lower extremity with minor to no pain? 

If you answered YES to all of these questions, then some of the focus can begin to shift over into foot/ankle strengthening and proprioceptive training.  Otherwise, continue with pain control, range of motion normalization, and weight bearing capacity.

There havebeen an number of studies that demonstrate positive outcomes and return to sport when there is an implementation of strengthening and proprioceptive training (2,3,6). 

You- jou et al., found in his study that implementing balancing exercises helped strengthen the ankle muscles and therefore create more stability, which is exactly what you want to develop post ankle sprains, especially for those athletes who have suffered reoccurring ankle sprains. 

3. What are some balance and strengthening exercises

 In the first part of this blog I introduced some basic single leg balance exercises, as those balance exercises get easier the progressions for balance will become more dynamic. They will challenge the ankle via unstable surfaces and added directional forces.

Dynamic balance exercises require the ability to first be able to carry out static (still) balance, and my requirement is 60 second holds.

Once you have accomplished that and have been able to carry out the forward step and hop to single leg balance, we transition to lateral movements.  With running, our cadence, step rate, and direction is very linear, but for trail and cross country runners you will need lateral ankle stability.  

 Figure 1: Double leg heel raise 3x25&nbsp;

Figure 1: Double leg heel raise 3x25 

Before you progress your dynamic balances however, I would work on general strengthening of the ankle. Here are some exercises that you can implement: 

1. Double leg Heel raises: I would recommend reading back into the posterior tib post where we went over the short foot position, which is what I implement with heel raises. Attempt to create an arch in the foot, and as you lift your heels you should feel most of the weight roll over your big toe, not the outside toes hold for 3 seconds and slowly return to the starting position. Repeat. 

 Figure 2: Ankle Inversion with Band 3x25 , 10 sec holds.&nbsp;

Figure 2: Ankle Inversion with Band 3x25 , 10 sec holds. 

When this gets easy then you would then progress to a single leg heel raise. 

 Figure 3: Ankle Eversion with Band&nbsp;

Figure 3: Ankle Eversion with Band 

2. Ankle Inversion with Band. Place the band around foot, below the toes, and create tension using the opposite leg as shown . Then point the foot down and inwards and hold for 10 seconds and slowly return to the starting position. Repeat 25 x. 

3. Ankle Eversion with Band: This is similar to the prior exercise except the direction changes to pointing the toes down and out.  Hold for 10 seconds and repeat 25x 

 

I really like the balance exercises because I think that they are more functional driven towards running. Strengthening is great, and needed however balance is where you get you judge where you are in terms of tolerating impact and evaluate how well and how fast your ankle reacts to the stresses and external instabilities. 

The Balance Exercise Rules: 

1. With dynamic movements start with:

-multidirectional reaching

-small lateral steps

-large lateral steps

-small lateral hops

 Figure 4: Star Excursion on stable surface: Single leg balance with contralateral leg reaching forward, sideways, back, and back to opposite hip&nbsp;  Reaching in all directions = 1 rep , Goal 3x5 Reps&nbsp;

Figure 4: Star Excursion on stable surface: Single leg balance with contralateral leg reaching forward, sideways, back, and back to opposite hip 

Reaching in all directions = 1 rep , Goal 3x5 Reps 

-big lateral  hops.

2. always start on a stable surface (even stable ground) 

3. Progress to an unstable surface ( foam pad/pillow) 

The start excursion reach is a great exercise to challenge balance and general lower extremity proprioception.  Today is used to help assess for asymmetries between legs in order to help identify for possible risks of knee or ankle injury (7). 

With the star excursion reach, you will be balancing on the affected foot/ankle and then reaching as far as you can forward, out to the side, back, and back cross body towards the opposite hip.  

As you are reaching you do want to maintain proper knee alignment and keep core engaged.

Once again when you master the reaching on the ground you will then progress to a foam pad. 

 Figure 5: Star Excursion on Unstable Surface &nbsp;3x5 reps&nbsp;

Figure 5: Star Excursion on Unstable Surface  3x5 reps 

 Figure 6: Lateral hop on stable surface. Goal is to stick the landing for 5 seconds. x20 each side . The Knee should maintain alignment with hip and foot.&nbsp;

Figure 6: Lateral hop on stable surface. Goal is to stick the landing for 5 seconds. x20 each side . The Knee should maintain alignment with hip and foot. 

Now lets jump into the lateral dynamic balance exercises. 

As seen below the lateral hop on a stable surface promotes ankle stability and improvement in ankle reaction to instability.

With the lateral hop: 

- You will start in 1/4 squat, make sure your knee is line with ankles and tracking over your foot, not facing inward
-You are going to hop side to side starting on the right foot and jumping to the left foot
-Land softly on the balls of your feet, mindful that your knee isn't coming past your toes or falling inward, then your heel softly rolls down, then you repeat to the opposite side.

 Figure 7: Lateral hop to unstable surface, goal is stick landing for 5 seconds x 20&nbsp;  Knee should be aligned with foot and hip.&nbsp;

Figure 7: Lateral hop to unstable surface, goal is stick landing for 5 seconds x 20 

Knee should be aligned with foot and hip. 

The PROGRESSION would be to do the same but now on an unstable surface like a foam pad.

Once you have handles doing these exercises the progression from here on out would be to slowly start going back to prior exercise routine.

For example:

1. squatting

2. Single leg squatting 

3. Box Step ups

4. Lateral Box Step ups.

Around this time (4-6 weeks for grade II and III sprains) that you are progressing back to usual work out routine. You can start assessing how you feel with jogging on level surfaces. If it feels good, start by jogging for 20 minutes. If you can do that without pain or excessive soreness that next day then increase by 5 minutes each run.  

If it takes a tad bit longer to progress your running tolerance ... guess what IT'S OKAY. 

 

Remember that it takes 6-8 weeks to develop  strength gains,  and studies have demonstrated that after 6 week of strengthening and balance programs there is a positive improvement in ankle stability (1,2,3,4,5,6)

Like many other injuries healing takes time, but so does rehabilitation. Do not get anxious, the goal is to train and strengthen enough do that you are less likely to experience another sprain in the future. 

 

TRAIN SMART,

JESSICA MENA DPT, CSCS, RUNNER

Feel free to email me for further questions/concerns: drjmenadpt@gmail.com

 

 

 

 

 

 

 

 

 

 

1.     Cleland JA., Mintken P, McDevitt A., Bieneik M, Carpenter K, Kulp  K., Whitman J.M. Manual Physical Therapy and Exercise in the Management of Patient With Inversion Ankle Sprain: A Multicenter Randomized Clinical Trial. Journal of Orthopaedic and Sports Physical Therapy. (2013) 43(7)p443

2.     Hanci E., Seir, U., Gur H., Akiva B. Eccentric Training Improved Ankle Evertor and Dorsiflexor Strength and Proprioception in Functionally Unstable Ankles. American Journal of Physical Medicine Rehabilitation. 2016  95(6)p448

3.     Ismail MM, Ibrahim MM, Youssef EF, El Shorbagy KM. Plyometric training versus resistive exercises after acute lateral ankle sprain. Foot Ankle Int. 2010;31(6):523–530.

4.     Han K, Ricard M, Fellinghma G. Effects of a 4-Week Exercise Program in Balance Using Elastic Tubing as Pertubation Force for Inidividuals with a History of Ankle Sprains. Journal of Orthopaedic and Sports Physical Therapy. 2009 39(4)p246

5.     Mattacola C.G., Dwyer M.K. (2002) Rehabilitation of the Ankle After Acute Sprain or Chronic Instability. Journal of Athletic Training.  37(4)

6.     Sefton M.J., Yarar, C., Hicks-Little, C.A., Berrytm J.W., Cordova, M.L. (2011) Six Weeks of Balance Training Improved Sensorimotor Function in Individuals with Chronic Ankle Instability.  Journal of Orthopaedic and Sports Physical Therapy.  41(2)’

7.     Stiffler MR, Bell DR, Sanfilipo JL, Hetzel SJ, Pickett KA, Heiderscheit BC. 2017. Star Excursion Balance Test Anterior Assymetry is Associated with Injury Status in Division I Collegiate Athlete. Journal of Orthopaedic and Sports Physical Therapy. 47(5)p339.

8.You-jou H (2015) Neuromuscular Control and Rehabilitation of the Unstable Ankle. World Journal of Orthopedics 6(5)p434-438

Ankle Sprains Part I:  Causes, Symptoms, and Phase 1 of Rehab

 2013 Cross Country Grade III Sprain (me right- inversion sprain ) and fellow football player grade III sprain (eversion sprain)

2013 Cross Country Grade III Sprain (me right- inversion sprain ) and fellow football player grade III sprain (eversion sprain)

In general, ankle injuries make up about 17% of all running injuries, half of these account for lateral ankle sprains (1)

Many of us have experience 1 or 2 ankle sprains, others many more. I have received a few questions in regards to what else can be done aside from Ice and elevate after spraining an ankle. I am here to help provide some guidance.

1.     What is an ankle sprain ?

The actual ankle joint itself is made up of the talus bone articulating with the tibia and fibula bones. In order to keep the ankle stable, strong fibrous tissues called ligaments surround the joint. These ligaments connect the bones together, keep the bones in their proper position, and provide stability.  An ankle sprains occurs when these strong supportive ligaments get stretched beyond their limits and tear. The tears can be very minor and some tears can be quiet severe to where you will notice swelling, discoloration, experience pain, limited range, and inability to even walk.

There are 3 types of ankle sprains:

1.     Inversion ankle sprain ( the most common)

2.     Eversion ankle sprain

3.     High Ankle Sprain

An inversion ankle sprain occurs when the ankle rolls out, and foot rolls under. This type of sprain will stretch and injure the ligaments on the outside of the ankle most commonly the Anterior talofibular ligament and the calcaneofibular ligament.  It occurs more with runners who land on the outside of their foot.

An eversion sprain happens less frequently and it occurs when the ankle rolls inwards the foot outward. This type of sprain stretches and injures the ligaments on the inside of the ankle, the deltoid ligament. Many times some poor footing on uneven surfaces or rocks. It is common also so suffer an inversion sprain and as your foot tries to correct itself. 

Lastly, high ankle sprains are the least common and occur when the foot is planted on the ground and the lower leg rotates inward, or when the foot is forcefully rotated outward. This type of sprain will injure and tear the syndesmosis which is the fascia/dense tissue that connects the tibia and fibula bones  together.

There are also different classification of sprains that are categorized by grades. The grade refers to how injured the ligaments are.

Grade 1 Sprains are very mild injuries, where the ligaments demonstrates slight stretching. Meaning the integrity of the ligament is intact.

Grade 2 sprains are moderate sprains, where there is a partial tear in the ligament/s. At this level the integrity of the ligament has been compromised, when examined the ankle will feel loose or less stable.

Grade 3 sprains, are severe sprains in which there is a complete tear of the ligament. Therefore clinically the ankle will feel unstable.

 My grade III sprain progression: Day 1, Day 2, Week 2, Week 4 (2015)

My grade III sprain progression: Day 1, Day 2, Week 2, Week 4 (2015)

 2.     How Do you know you sprained your ankle?

 I know there have been times where you gingerly roll your ankle and you recover pretty well, in those circumstance you probably have not sprained anything.  When you have experienced a true ankle sprain if you will notice soreness, swelling, sometimes bruising, and the level of stiffness and weight bearing pain varies on the grade of a sprain.

For example:For grade 1 ankle sprains, you will experience some tenderness and very mild swelling. You may feel sore but it may not necessary limit your activity or you may even keep on running without any problem

A grade 2 sprains you will experience pain after rolling your ankle, and notice minor to moderate swelling immediately. You may experience minor bruising the next day and notice some soreness with weight bearing.

With grade 3 sprains, you may hear or feel a pop in the ankle, followed with pain and moderate to severe swelling immediately.  Weight bearing will be painful, and after a few minutes experience range of motion loss ( due to pain and swelling) and will notice bruising.

 

3.     What you should do after spraining your ankle- Phase 1/3

 Grades 1 Sprains

Ice it, weight bear as much as you can tolerate if painful. Studies show that there is a significant benefit to weight as compared to non weight bearing. Patient who managed to bear weight and work on their range of motion ( if noted) returned back to sportin 4.6 days. (3)

Grades 2-3 sprains:·    

 Immediately after : R.I.C.E !!! ( Rest, Ice, Compression, Elevate). For the last couple of years, icing has been a hot topic. Recent research neither supports or discredits icing. A recent article just came out (3/8/17) stating that icing does suppress inflammation and some aspect of healing, however it does not retard muscle regeneration, which has been the biggest argument for those against icing. (4) As well as the idea that inflammation is part of the healing process, and cannot have tissue remodeling without inflammation. I agree with those points, the problem is when there is too much swelling that it negatively affects function, range of motion, and increases pain. For most people, ice has been helpful.

On a personal note, I have had grade 3 sprain on both ankles, and I iced quiet frequently, along with my rehab exercises I was back jogging in 4 weeks and running in 6 weeks. So I attest to its benefits, but that is up to you!

·      Wrap the ankle with an ace wrap, or wear a compression stocking to avoid development of further swelling.

·      Weight bear at tolerated- use a lace up brace (2)

·      Once you have gained control of the swelling with elevation, day 2-3 you want to begin doing therapeutic exercises. Studies have shown a significant increase in function in patients with grade I and II sprains, and those with chronic ankle sprains with physical therapy interventions (1, 5)

PHASE 1 OF REHAB BEGINS WITH : Normalizing range of motion, and balance.     

 1. Standing Gastroc Stretch&nbsp;  3x 30-60 sec bouts&nbsp;  If weight being is painful you can do this stretch long sitting, using a belt or towel and pull your toes towards you.&nbsp;

1. Standing Gastroc Stretch 

3x 30-60 sec bouts 

If weight being is painful you can do this stretch long sitting, using a belt or towel and pull your toes towards you. 

 2. Further work on range of motion with this WALL DORSIFLEXION exercises  Affected foot about 3 inches from the wall, foot straight, knee in line with toes and try to see if you can get your knee to touch the wall. DO not let the heel lift from the ground. - Hold for 5 seconds and REPEAT  x20&nbsp;

2. Further work on range of motion with this WALL DORSIFLEXION exercises

Affected foot about 3 inches from the wall, foot straight, knee in line with toes and try to see if you can get your knee to touch the wall. DO not let the heel lift from the ground. - Hold for 5 seconds and REPEAT

x20 

 Single leg balance on stable surface first, then unstable.&nbsp;  First try on the ground, if that is easy or soon gets easy, and able to hold for 1 min, then progress to foam pad.&nbsp;  Goal is one min!&nbsp;  5 min of balance , hold for as long as you can hold. NO TRUNK SWAYING, TO KNEE INSTABILITY.&nbsp;  Once this gets easy then we progress to forward and lateral steps to balance.&nbsp;

Single leg balance on stable surface first, then unstable. 

First try on the ground, if that is easy or soon gets easy, and able to hold for 1 min, then progress to foam pad. 

Goal is one min! 

5 min of balance , hold for as long as you can hold. NO TRUNK SWAYING, TO KNEE INSTABILITY. 

Once this gets easy then we progress to forward and lateral steps to balance. 

 Forward Step to Single Leg Balance&nbsp;  Step forward to single leg balance, or you can do a forward hop to balance.  Stick the landing and hold for 5-10 seconds, and Repeat x20   Trunk, hips, and knees should be stable and steady.&nbsp;

Forward Step to Single Leg Balance 

Step forward to single leg balance, or you can do a forward hop to balance.

Stick the landing and hold for 5-10 seconds, and Repeat x20

Trunk, hips, and knees should be stable and steady. 

Yes strengthening will play a huge role after the acute phase (which lasts 7-14 days)

The goal in the first phase post sprains is to control the swelling, manage the pain, begin weight bearing (if painful), and begin normalizing range of motion.

A lot of runners benefit from manual treatment also, so if you do not have a physical therapist that may help you with that: stretch, foam roll as tolerated. The goal to is get the same amount of range of motion as the non-injured side.

This will take a few weeks 3-4 weeks for grade II-III sprains. Pain attention to how your body reacts to the exercises. 

I would advice to get a higher grade sprain checked out by a physical therapist. 

 

STAY TUNED FOR PHASE 2 REHAB that will be posted next week!

TRAIN SMART

RUN HAPPY,

JESSICA MENA DPT, PT, CSCS

 

1.     Bleakley CM, O’Connor SR, Tully MA, et al. E ect of accelerated rehabilitation on function after ankle sprain: randomized controlled trial. BMJ. 2010;340:c1964. http://dx.doi.org/10.1136/bmj.c1964

 

2.     Kerkhoffs GM, Rowe BH, Assendelft WJ, Kelly KD, Struijs PA, van Dijk CN. Immobilization for acute ankle sprain. A systematic review. Arch Orthop Trauma Surg. 2001;121:462-471.

 

3.     Martin, R. L., Davenport T.E., Paulseth, S., Wukick D.K, Godges, J. Ankle Stability and Movement Coordination Impairments: Ankle Ligament Sprains: Clinical Practice Guideline Linked to the International Classification of Functioning, Disability and Health From the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic and Sports Physical Therapy. 2013; 43(2)

 

4.     Singh D., Lonbani Z.B., Woodruff M.A., Parker T.J., Steck, R., Peake, J.M. Effects of Topical Icing on Inflammation Angiogenesis, Revascularization, and Myofiber Regeneration in Skeletal Muscle Following Contusion Injury. Frontiers in Physiology Journal. 2017. doi:  10.3389/fphys.2017.00093

 

 

5.     Rijn RM, van Heest JA, van der Wees P, Koes BW, Bierma-Zeinstra SM. Some bene t from physiotherapy intervention in the subgroup of patients with severe ankle sprain as determined by the ankle function score: a randomised trial. Aust J Physiother. 2009;55:107-113.

6.     Van den Bekerom, M., Struijs P.A., Blankevoort, L., Welling, L., van Dijkm N.C., Kerkhoffs, G.M. What is the Evidence for Rest, Ice, Compression, and Elevation Therapy in the treatment of Ankle Sprain in Adults?  Journal for Athletic Training. 2012. 47 (4)

Iliotibial Band Syndrome

competition-exercise-group-3629.jpg

Iliotibial Band Syndrome (ITBS) is another overuse injury experienced by some athletes, more so runners and cyclists. According to Ferber et al it is the second leading cause of lateral knee pain in runners (2). It is most commonly described as a friction injury at which the tendon “rubs” over the lateral femoral condyle of the knee creating pain (1) that can present as sharpness, burning, and sometimes swelling. 

ITB Anatomy: 

ITB-Syndrome-1_l.jpg

The ITB is a broad band of dense connective tissue that originates from the fibers of the gluteus maximus , medius, and tensor fascia late. It runs down the side of the leg and inserts at the lateral aspect of the knee joint; the lateral femoral condyle and infracondylar tubercle of the tibia and fibular head to be exact. 

The primary function of the ITB is to help stabilize the hip and knee. The action of the muscle is to help flex the hip (raise the leg up), abduct the hip (bring the leg out to the side), and internally rotate the leg (with the knee straight, turns the leg inward).

This muscle commonly gets overworked, but naturally this will occur because for running you have to flex the hip. The problem then comes down more so to mechanics and whether someone is flexing the hip with excessive leg internal rotation or not. 

Symptoms and Causes of ITBS: 

As stated previously ITBS is commonly described as sharp and or burning pain on the lateral aspect of the knee pain that is mostly felt during the loading phase of gait when the knee is bent between 20-30 degrees (4). In addition, many runners with ITBS have reported pain exacerbated with downhill running 

There have been a handful of studies that have thoroughly investigated the actual REASON to why athletes develop ITBS. We know structurally what tissues become strained and irritated (5) but what is more important is the WHY and HOW it got to that. 

A few researchers have investigated how mechanics differ from athlete with and without ITBS syndrome, and a group of them (5,6) looked at mechanics during an running exhaustive state. What they found was that that towards the end of an exhaustive run, runners diagnosed with ITBS demonstrated increase rearfoot (heel) strike which led to increase of internal rotation of the tibia during loading.  When this mechanical outcome occurs what end up happening is that the internal rotation of the tibia (lower leg) increases the pull of the distal end of the ITB. Therefore, the researchers speculated that the repetitive internal rotation led to irritation of the ITB tissue. Ferber et al also found in his study that his group of runners with ITBS exhibited “significant hip adduction angle as well and tibial internal rotation (2).” Why is that problematic? Well, when a runners demonstrates an apparent hip drop that leads to the over stretching of the ITB, and if that is persistently happening the ITB is consistently being stretched and strained especially at the site of insertion (the knee). So why does a hip drop happen you may ask.

knee valgus.png

We have a few muscles that help support the hip aside from the TFl/ITB and those are our  glute muscles. The ITB along with the gluteus medius and some fibers of the gluteus maximus play an important role in stabilize our hips during running. Meaning, if they are strong enough and coordination enough they will limit how much our hips drop (adduct). When there is an increase in hip drop (adduction) that leads clinicians to the speculate that there may be a power discrepancy at the hips. Please do not be fooled that just because you run , cycle, work out etc. you assume that you will just naturally get strong in the right places. I have heard clients state “I run, my hips shouldn’t be weak right?”  Im sorry to break it to you, but unfortunately thats not the case. 

Researchers also understand that and have carried out studies looking at hip strength in runners with ITBS. Frederickson et al led a study comparing hip strength in runners with and without ITBS and concluded that  ITBS running group demonstrated increase hip abductor WEAKNESS compared to the control group.

Treatment for ITBS: 

Most of the time, in order for this injury to resolve itself, we have to treat the problem not the symptom.

 Glute medius weakness leads to hip drop (trendeleburg sign)

Glute medius weakness leads to hip drop (trendeleburg sign)

As I have presented above, the problem tends NOT to be that your ITB is stiff. As a matter of fact this band is so dense and fibrous it's actually EXTREMELY difficult to stretch it. You will have better luck attempting to stretch the TFL muscle vs foam rolling the whole side of your leg. So please stop bruising your ITBs , its less helpful that you think. 

Treatment will be dictated why movement fault found, and as you have read, a majority of the faults associated with ITBS syndrome and tibial internal rotation and increase hip adduction during load. Therefore the hip muscles should be assessed for any weakness and the foot mechanics should be assessed for any weakness leading to foot pronation. 

You will fall into one of these categories of impairment if you truly have 100% ITB syndrome. 

The answer will stem from strengthening any weakness at the hip and foot and possible changing mechanics if needed. 

Icing the area will help with pain and anti-inflammatories may make you feel better, but get after the root of the problem versus just addressing pain. 

Beginner Strengthening Exercises for Hip Abductor Weakness

The STAPLES: 

- Clams

-Firehydrants

- Sidestepping /Crab Walk

Overpronator?

- Short foot exercises

- Practice giving yourself an arch as often as possible through out the day. 

 

 

Remember, when it comes to injuries- THERE IS ALWAYS A REASON/CAUSE, you don't just get pain out of nowhere. 

 

- TRAIN SMART to KEEP RUNNING!

JESSICA MENA PT, DPT, CSCS 

 

 

 

 

 

 

 

 

References: 

1.     Fairclough J, Hayashi K, Toumi H, Lyons K, Bydder G, Philips T, Bejamin M. The Functional Anatomy of the Iliotibial Band During Flexion and Extension of the Knee: Implications for Understanding Iliotibial Band Syndrome. Journal of Anatomy. 2006 208. P:309-316

 

2.     Ferber R, Noehren B, Hamil J, Davis R. Competitive Female Runners with a History of Iliotibial Band Syndrome Demonstrate Atypical Hip and Knee Kinematics. Journal of Orthopaedic & Sports Physical Therapy. 2010 40:2 pgs: 52-58

 

3.     Fredericson M, Cookingham CL, Chaudhari AM, et al. : Hip abductor weakness in distance runners with iliotibial band syndrome. Clin J Sport Med, 2000, 10: 169–175

 

4.     Hamill J, Miller R, Noehren B, Davis R. A Prospective Study of Iliotibial Band Strain in Runners. Clinical Biomechanics. 2008 23 p. 1018-1025

 

5.     Miller RH, Lowry JL, Meardon SA, GilletteJC. Lower extremity mechanics of iliotibial band syndrome during an exhaustive run. Gait Posture. 2007;26:407-413. http://dx.do

 

 

6.     Terry GC, Hughston JC, Norwood LA. The Anatomy of the Iliopatellar band and iIiotibial tract. Am J Sports Med. 1986;14:39-45. 

 

The Pelvic Floor- A Missing Link

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It’s time to talk about a topic some people would rather avoid, and that’s the pelvic floor! It is common to forget about the pelvic floor when we talk about core strength, so let me say this loud and proud, DO NOT ignore the pelvic floor, especially all you female distance runners. Even in our “modern” era, talking about pelvic floor dysfunctions is something really uncomfortable and even shameful to bring up and it really shouldn’t be.  A healthy strong pelvic floor is really just as important as the strength of any other muscle on your body. 

The muscles that make up this area support your organs and are in charge of containing or excreting contents from our bodies (1).  And just like any other muscles in our body, when muscles are not activated or trained properly, over time weaknesses will develop. Pelvic floor weaknesses then begin to manifest as urine leakage, pain with intimacy, constipation, organ prolapse, and or back pain. 

In a 2015 study conducted by Thyssen et al., they found that 151/291 elite female athletes and dancers (average age of 22.8 years old) experienced some sort of urine loss in general. 125/291 athletes (51%) experienced urine loss during their sport (4). Similarly, in another study conducted by Borin et al, found that there was a higher correlation between athletes and decreased pelvic floor muscle pressure and incontinence (1). This is important to note, because what this tells us, is that athletes are at a HIGHER risk for pelvic floor dysfunction simply because we are not training our pelvic floor, and we NEED to be doing so.

When it comes to running, we have to remember that running is a high impact sport.  Every time our foot strikes the ground, all of our organs move up/down in our cavity and bounce onto our pelvic floor. This causes stretching of the pelvic floor muscles and the supporting tissues. Now imagine what happens when a WEAK pelvic floor is forced to try to support all the forces and movement stress that occurs during a run. Well, it gets weaker, longer, less supportive, and leads to problems. Our pelvic floor will do as much as it can with what it can but over the course of time increase pressure or stress may lead to noted leaking. Sometimes you may have heard patients, friends, team mates state something along the lines of “when I do jumping-jacks/jump/ jump-rope/sneeze/sprint/run for longs periods of time I leak a little.” For the most part, it is taken as something normal for women, especially if they have experience vaginal childbirth. This type of symptom is categorized as stress urinary incontinence and I will state that: no it is not okay, and that is NOT normal. Luckily for ladies or men who experience this, yes there is a solution and that is pelvic floor exercises.

How does this happen?

The pelvic floor form a bowl-like structure that stretches from the tailbone to the pubic bone and from one sitting bone to the other. It is also a supportive structure to the abdominals and back muscles and play a role in stabilizing and supporting the spine. Alone, when the pelvic floor contracts it lifts our internal organs and tightens the sphincters of the urethra, anus, and vagina. Relaxing of the pelvic floor allows for passage of excrements.  Therefore, as you might foresee the function of the pelvic floor is supportive and sphincteric. Supportive in the sense that as you read the pelvic floors role is to support our organs, reduce the force of gravity of our contents, and reduce intra-abdominal pressure in cases such as coughing/sneezing/lifting/vomiting/straining. The sphincteric function is to compress the urethra and rectum from continence and maintain continence during high pressure of the urethra and bladder (such as during sports).  

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Stress urinary incontinence occurs from poor sphincteric closure (due to weakness of muscles) with increased abdominal pressure. Activities and high impact sports have been associated with a higher prevalence of developing urinary incontinence especially in women. What researcher and clinicians suspect happens is that repetitive and prolonged high impact activities leads to fatigue and overtime weakening of the pelvic floor (2).

So what things can make your pelvic floor weak?

1.     Pregnancy and Childbirth

2.     Injury or trauma

3.     Lack of exercise

4.     Too much straining on the toilet

5.     Heavy lifting

6.     Obesity

7.     Men: prostate cancer

There are three types of stress incontinence and they are:

Type I: leakage with strenuous activity (sports) , sneezing

Type II: leakage with moderate activity such as moderate cough, jogging

Type III:  Leakage with minimal activity such as rolling over in bed.

How can you strengthen the pelvic floor?  

There has been numerous studies that has demonstrated that training the pelvic floor muscles lead to a reduction in incidents in individuals that suffer from stress urinary incontinence. Therefore, strengthening is imperative for improving ability to tolerate high impact activities without incidents.

A nice way to start working on the pelvic floor is with the basics. The most basic task is to become aware of your pelvic floor and then learn how to engage it. This can be attempted by “stopping the flow of urine” midway through emptying. Doing so will not necessary strengthen the pelvic floor but it is a great way for you to get a feel and understand where those muscles are. After you have been successful with that start with doing exercises on your back.

Exercise 1: Kegels

  • Lay on your back, knee bent, and feet shoulder width a part.
  • Begin with your diaphragmatic breathing (inhale and expands the abdominal area and gently exhale).
  • As you exhale begin by closing and drawing up the muscles around the back passage WITHOUT tightening your buttock and muscles around the urethra (front passage), as if you are trying to stop the flow of urine.
  • On your next inhale relax and SLOWLY leg go.
  • Repeat for about 3- 5 minutes, or until you feel tired.
  • As you get better you will hold the contraction for 10 seconds—then 20 sec –
  • The actual contraction will at first feel very faint and as you get better it will be more prominent.

Practice, practice, practice, and then eventually implement to your functional activities. 

Once you get the hang of this, you can try to do this laying on your side or back, then proceed to standing.

Implement Kegels with your Bridges, Squats, and Core exercises.

Be very mindful of your pelvic floor as you perform your usual core exercises. Many times we focus too much on just bracing the abdominals that we end up bearing down and pushing the pelvic floor down instead of lifting. 

 

Tips While Running:

  • Make sure you use the restroom before going on your runs- you want to be empty to minimize excess bladder and intestinal pressure
  • Avoid over drinking during your run, and if you drink a lot, and eel the need to urinate, then just stop and urinate
  • Every mile check yourself and work on lifting for a few seconds and proceed with running.
  • If you are running down hill, make and effort to lift the pelvic floor.

 

Remember fellow runners, developing strength is a lengthy process.

Seeing actual changes may takes a few weeks, especially during your actual runs.

Ladies want to learn more- visit your local Women's  Health Physical Therapy Specialist! 

 

 

 

Be patient

Be persistent

Work on this daily and weekly.

 

Train smart!

Happy Running, 

Jessica Mena PT, DPT, CSCS

 

 

 

 

 

References

1. Borin LC., Nunes FR., Guirro EC. Assessment of pelvic floor muscle pressure in female athletes.  American Academy of Physical Medicine and Rehabilitation. March 2013. 5(3) 189-193

2. Garcia-Sanchez E, Rubio-Arias J, Avila-Gandia V, Ramos D, Lopez-Roman J. Effectiveness of Pelvic Floor Training in Treating Urinary Incontinence in Women: A Current Review. Actas Urologicas Espanolas. 2016; 40(5).

3. Raizada V., Mittal R.K. Pelvic Floor Anatomy and Applied Physiology. Journal of Gastroenterology. Clinic North America 2008. September 37 (3) 493

4. Thyssen, H.H, Clevin O.S., Lose G.  Unirary Incontinence in Elite Female Athletes and Dancers. Journal of International Urology. 2002 13:15-17

 

 

 

 

Does Running Cause Knee Arthritis- Review of Articles

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I have been a long distance runner for about 16 years now and as I get order I am experiencing less aches and pains than I did in my younger years, which is contrary to what many may expect.  Therefore, I wanted to investigate if long term distance running could actually increase the rate of arthritis development at the knee joint. 

This article will shed some light on what research says on the matter and I hope you feel delightfully surprised.

What is Arthritis?

Arthritis is the inflammation of a joint, and there are actually many types of arthritis. The most common form is osteoarthritis.

Osteoarthritis (OA) is the degeneration of bone surfaces, in other words “wear and tear” of a joint. Usually the cartilage will wear away first, which means there will now be exposure of bone surfaces (decreased joint space). When the bones are exposed there will be bone on bone rubbing which leads to pain, grinding , swelling, buckling, and stiffness.

What causes Osteoarthritis?

There are many factors are contribute to the wear and tear of the joint. One of them is your age. I tell my clients to remember that all of our tissues expire, we just have a long expiration date. 

·      Individuals over the age of 50 tend to have or develop arthritis. Makes sense, 50 years of loading a joint will eventually cause some wearing out.

·      Being overweight increases the chance of developing OA. More load causes more stress, and eventually more wear and tear compared to someone who is not overweight. 

·      History of knee injury- such as ACL tears, severe meniscus injuries, meniscectomies (removal of meniscus) because the integrity of the knee was been altered , causing more instability and thus more stress and rubbing.

· Strenuous repetitive activities - now this list varies from article to article. Some list long distance running as a strenuous activity other do not. (2,4)

What does research say about running and knee osteoarthritis? 

As a researched I found articles dating back to 1986 researchers have no found a strong link between lifelong distance running and early development of OA. A study in 2008 looked at 45 long distances runners and 53 controls (non runners). The runners were the average age of 58 when the study started in 1984 and were followed through 2002. The goal of the study was to document difference in knee osteoarthritis over the course of the years in runners and non runners. Towards the end of the study the researchers took and analyzed radiographs in both groups and found that the runners did NOT demonstrate more OA development than the non- running group (3). 

A recent 2017 research report was published by the Journal of Orthopaedic and Sports Physical therapy that looked at the very question.  The purpose of this article was to do a meta- analysis  of articles evaluate whether there is an association between knee and hip OA with running.  They analyzed 25 articles and looked at the prevalence of OA in recreational runners, competitive runners (professional/elite) and sedentary individuals.

Alentorn-Geli et al found after analyzing 25 peer reviewed articles that in general running WAS NOT associated with knee OA. The literature demonstrated lower odds for Hip and knee OA in  recreational runners  compared to competitive runners and non-runners. Competitive runners did demonstrate a higher association to joint degeneration compared to recreational runners. Which the researchers explained that in competitive runners:  age, workload, and sex were clear factors to that likelihood of OA development (>50, female, olympic distance runners) (6).  Alentorn- Geli et al, also reported that in 2 studies, runners that had ran more the 15 years vs runners who had  ran less than 15 years demonstrated a higher association to knee OA to the overall population by 17.2%. 

Basically:  RUNNING IS NOT ASSOCIATED WITH DEVELOPMENT OF OSTEOARTHRITIS, and if you have been running for +15 years like myself expect some degeneration (not shocking). 

Some limitation to the studies however were that the actually running workload were not specified between competitive runners and recreational runners.  It would be interesting to see what workload of running is too much. 

 

With that being said:  KEEP ON RUNNING!

 

 

TRAIN SMART

RUN HAPPY

JESSICA MENA PT, DPT, CSCS, RUNNER

 

 

 

 

 References

1. Alentor-Geli E, Samuelson K, Musahl V, Green C, Bhandari M, Karlsson J. The Association og Recreational and Competitive Running with Hip and Knee Osteoarthritis: A Systematic Review and Meta- Analysis. Journal of Sports and Orthaepedic Physical Therapy. 2017. 47:6  DOI:10.2519/jospt.2017.7137

2. Beckett J, Jin W, Schultz M, et al.  Excessive running induces cartilage degeneration in knee joints and alters gait of rats. J Orthop Res.  2012; 30: 1604– 1610.  

3. Chakravarty E, Hubert H, Lingala V, Zatarain E, Fries J. Long Distance Running and Knee Osteoarthritis. American Journal of Preventative Medicine. 2008 35:2

4.Felson DT, Zhang Y, Hannan MT, et al.  Risk factors for incident radiographic knee osteoarthritis in the elderly: the Framingham Study. Arthritis Rheum.  1997; 40: 728– 733

5. Konradsen L, Hansen E, Sondergaard L. Long Distance Running and Osteoarthritis. The American Journal of Sports Medicine. 1990 18:4 https://doi.org/10.1177/036354659001800408

6. Kujala UM, Kaprio J, Sarna S. Osteoarthritis of weight bearing joints of lower limbs in former elite male athletes. BMJ. 1994;308:231-234. https://doi.org/10.1136/bmj.308.6923.231 

Medial Tibial Stress Syndrome

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Medial tibial stress syndrome ( MTSS) also commonly knows as “shin splints” and as medial tibial traction periostisis is a very common overuse injury.  With MTSS the athlete presents with pain  along middle or lower half of the posteriormedial border of the tibia during loading activities such as running, walking, and jumping (2,3,4). Shin splints make up 60% of all lower leg injuries in all athletes,  4% to 20% in military personnel,  and 9.5% specifically to runners (5).  Garnock et al, explained that MTSS recovery times can range anywhere from 4 weeks up until 18 weeks with a reoccurrence rate of 20-30x in those individuals who with a history of MTSS compared to those without a history (4). Unfortunately, for those athletes experiencing this injury ceasing training is recommended especially if their pain surpasses a level 4 on a 10 point pains scale (5). For many years now, researchers and clinicians have attempted to find a definitive cause to MTSS as well as the best course of treatment but have fallen short. 

What Exactly Is Shin Splints? 

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The exact cause of shin splints has still not been validated but theories have been proposed to explain its development.

Theories:

1.     MTSS caused from repeated bowing of the tibia causing cortical bone microtrauma

2.     Tractioning/separation of the tibial periosteum (connective tissue that covers the tibial bone).

Essentially both theories lead to the belief that there is an irritation of the connective tissue of the muscles that attach to the posterior medial surface of the tibial bone. This connective tissue gets stressed from repetitive stretching and insesant pulling from over activation of the surrounding muscles. In the first theory, researchers propose that excessive rearfoot (heel) eversion leads to increase bowing at the middle section of the medial tibial bone leading to bone micro trauma. However, this cannot be completely supported because there have been positive links between MTSS and increases in both pronation and supination of the midfoot, What this does demonstrate is that there is in fact a mechanical component to MTSS (1,6).

 In regards to the second theory, there has been a research shift as to what muscle exactly leads to the shin splints. Some researchers propose that the main culprit to MTSS has been the posterior tibialis muscle which leads to mechanical faults and increase stress at the tibial bone.  However, more recent research is demonstrating that the  soleus muscle and the flexor digitorum longus (FDL) are the muscles that clinicians need to focus on (1,3,4,6,10) . Studies have demonstrated that subjects with MTSS demonstrate increase work in the soles muscle vs the posterior tibialis.  This had lead researchers to hypothesize that maybe the soleus overworking leads to an increase in traction of the underlying fascia and  this increases passive tension of the FDL myofascia which attaches at the most common site of pain in MTSS subjects (2). 

Anatomy: Actions of Muscles That Attach to Tibia

1. Flexor digitorum longus (FDL):  Plantar flexes ankle and IP 2-5 ( points  foot and toes) inverts the midfoot

2. Tibialis Posterior : Plantar flexes and inverts our foot/ankle

3. Gastroc: Plantar flexion of ankle and knee

4. Soleus -  plantar flexion of ankle

Risk Factors to Developing MTSS:

Even though the exact cause of shin splints is unknown there have been several studies that have been able to demonstrate who may be at risk to developing MTSS (3,4, 9,11).

Top Risk Factors according to Research (4, 11)

1.     Females: more common in females in all studies.

2.     Increased Weight/BMI : Theory that carrying heavier loads with poor bone adaptation to increase loading stress

3.     Higher Navicular drop – increase >10mm of drop, leading to poor absorption of load and stress at the lower leg and foot

4.     Previous History of MTSS – in large a good clinical risk factor, are 18-20x more likely to demonstrates reoccurrence of MTSS.

5.     Greater Hip External Rotation: Theory that it may produce a different running style/mechanics that increases load on the tibia or muscles that attach to posteriolateral tibia.

Extrinsic Risk Factors (11)

1.     New to sport/ such as running

2.     Increasing running intensity too fast

3.     Increasing running distance too fast

4.     Running on harder terrains

5.     Running in old running shoes

Prevention and Treatment:

Lets be clear, if this was easy to treat and understand by now there would be a clearer reason for etiology and less cases of shin splints.

But there is not, the cause of MTSS is still unclear which in turns makes it difficulty to treat.

If you take it back to the basics, it essence it is an irritation of a tissue structure, so therefore decrease activity and rest becomes imperative especially for those with higher pain scores and acuteness.

More recent research has looked at the use of modalities to help with pain and function.  Gomez et al. found that the use of a single shockwave therapy session in conjunction with strengthening and stretching of the lower leg muscles for 4 weeks resulted in improved running times by 17 minutes vs. just the exercise group. However another study by Newman et al found that shockwave therapy didn’t statistically help with MTSS.

Shulze et al. approached treatment manually with fascial release via strong focal pressure, pressure was reduced when the patient reported no pain with the pressure.  After doing this on 32 patients he found 53% of patients were pain free after treatment, and 19% could run more without pain. The limitation of this study however is that it is unknown what happened long term.

As a clinician, I do think the best course of treatment is always going to be looking at the big picture. We have to ask ourselves: What does your movement /running gait look like?  How strong do you test in all the muscles from the hips down? Is your foot absorbing load effectively and optimally? Are there any muscle or joint restrictions in the lower quarter?

When you put that all together and find the biggest deficits it may be easier to treat the whole lower quarter system and reduce any compensation and deviations.

Icing , taping, rest will all help calm down the symptoms, but at the end of the day there is a weak link that needs to be discovered and optimized.

Summary: there are many common risk factors, but each person experiencing medial tibial stress syndrome may demonstrate a slight variation. 

Therefore, I highly recommend that you visit your local movement expert, a licensed physical therapist. They will be able to analyze your movements and search for any impairments that you may present with. 

 

TRAIN SMART, STAY HEALTHY, AND STAY ACTIVE.

- JESSICA MENA PT, DPT, CSCS

 

 

 

 

 

 

 

 

 

 

 

REFERENCES

1.     Akiyama K Noh B, Fukano M, Miyakawa S, Hirose N, Fukubayashi T. Analysis of the Talocrural and Subtalar Joint Motion in Patients with Medial Tibial Stress Syndrome. Journal of Foot and Ankle. 2015. 8:25

2.     Brown AA. Medial Tibial Stress Syndrome: Muscles Located at the Site of Pain.  Journal: Scientifica. 2016. doi:  10.1155/2016/7097489

3.     Franklyn M, Oakes B. Aetiology and Mechanisms of Injury in Medial Tibial Stress Syndrome: Current and Future Developments. World Journal of Orthoedics. 2015. 6(8) 577-589

4.     Garnock C, Witchalls J, Newman P. Predicting Individual Risk for Medial Tibia Stress Syndrome in Navy Recruits. Journal of Science and Medicine in Sports. 2017. Vol. 22

5.     Ohya S, Nakamura M, Aoki T, Suzuki D, Kikumuto T, Nakamura Em, Ito W, Hirabayashi R, Takabayashi Tm Edama M. The Effect of a Running Task on Muscle Shear Elastic Modulus of Posterior Lower Leg.  Journal of Foot and Ankle. 2017 10:56

6.     Schutte KH, Seerdan S, Venter R, Vanwanseele B. Influence of Outdoor Running Fatigue and Medial Tibial Stress Syndrome on Accelerometer-Based Loading and Stability. Journal of Gait and Posture. 2018 59 p 222-228

7.     Schulze C Finze S, Bader S, Lison A. Treatment of Medial Tibial Stress Syndrome Accordingo to the Fascial Distorsion Model: A Prospective Case Control Study.  The Scientific World Journal. 2014.

8.     Gomez Garcia A, Ramon RS, Gomez MC, Benet MR, Chaustre Ruis DM, Cardenas LEtrado FP, Lopez-Illescas A, Alarcon Garcia JM. Shockwave Treatment for Medial Tibial Stress Syndrome in Militart Cadets: A Single-Blind Randomized Controlled Trial. International Journal of Surgery. 2017, Oct- Vol 46: p 102-109

9.     Reshef N, Guelich DR. Medial Tibial Stress Syndrome. Clinic In Sports Medicine. 2011. 31:2 p. 273-290.

10.  Winkelmann ZK, Anderson D,  Games K, Eberman LE. Risk Factors for Medial Tibial Stress Syndrome in Active Individuals: An Evidence: Based Review. Journal of Athletic Traninig. 2016. 51(12) p1049-1052

11.  Reinking MF, Austin TM, Richter RR, Krieger MM. Medial Tibial Stress Syndrome in Active Individuals: A Systematic Review and Meta-Analysis of Risk Factors. Journal of Sports Health. 2016. 9(3).

12.   Newman P, Adams R. Shockwave Treatment for Medial Tibial Stress Syndrome: A Randomized Double Blind Sham- Controlled Pilot Trial. Journal of Science and Medicine in Sport. 2017. 20(3). p 220-224