Running Injuries of the Foot and Ankle - PowerPoint Presentation

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Running Injuries of the Foot and Ankle

18th Annual Primary Care and Sports Medicine SymposiumJanuary 26th, 2018Andy Davis MSPT, LATSport and Spine Clinic of Weston

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Disclosure

No conflict of interest or company affiliation for this presentation.

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Running

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Anatomy

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Foot and Ankle Injuries

Tendonopathies (Achilles and Posterior Tibialis TendonPlantar FascitisAnkle SprainsFoot fracturesNerve Conditions

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Achilles Tendonapthy

Is the largest tendon of the body and connects the

soleus

, medial and lateral

gastrocnemius

to the

calcaneus

.

Most common sites of injury are at the

midportion

(2-6 cm proximal to the insertion) and at the insertion spot specifically

Prevalence in distance runners has been reported at 5-18% of the total injuries in runners

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Achilles Tendonopathy

Etiology is

multifactorial

Intrinsic factors (tendon

vascularity

, age, gender, body weight, muscle weakness, ROM, lower limb misalignment)

Extrinsic factors (training errors, running technique, footwear, running surface)

Biomechanical variable – hip strength and decreased neuromuscular control of gluteus

medius

and

maximus

(

Creaby

et al, 2017, Am College of Sports Med)

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Achilles Presentation

Mean age 30-50 and more common in malesDecreased PF strengthDecreased PF endurancePain with increased loading walking down stairsTendon thickening/swellingDecreased dorsiflexion ROM (Tenforde et al, 2016, Phys Med Rehabil Clin N Am) (Rabin et al, 2014, J Foot Ankle Research)

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Achilles

Mid –Portion: Pain with direct pressure over the distal third of the achilles (within 2-6 cm of insertion)Insertional: Pain with direct palpation along the medial/lateral aspect of posterior calcaneus. Longer recovery time

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Achilles Tendonopathy (AT)

Runners with

insertional

achilles

tendonopathy

use a greater range of DF

vs

normals

– correlates to increased

symptom

severity

(

Chimenti

et al, 2016,

Orth

Sports Phys

Ther

)

Individuals with AT, had increased DF position with hopping – creating an increase in stretch.

Soleus

activity is reduced

(

Debenham

et al, 2016 J

Sci

Med Sport)

Hip neuromuscular control is altered in runners with AT, specifically gluteus

medius

(

Creaby

M, et al 2017 Am Col Sports Med)

(Kim S, Yu J, 2015 J Sports Science and Med)

(Smith M, et al, 2014 Med and Science Sport and

Exericse

)

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Achilles Treatment

Strong evidence for eccentric strengthening to promote healing in

tendonopathies

as well as strengthening of

soleus

muscle with bent leg exercises.

Pain monitoring – utilizing the visual analog pain scale to give reference point for the patient and patient education

(

Sibernagel

, JOSPT 2015)

Tendon Load Management – avoid hills and reduce the running volume, may have to cross train. Isometric exercises moving into heavy slow resistance.

(

Kountaris

and Cook 2007, Best

Prac

Res

Clin

Rheumatiol

) (Cook and

Purdam

2009, Br J Sports Med)

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Running Mechanics and AT

Pain is usually at propulsive phase of stance, generally not at loading responseWith excessive DF at midstance, causes increase in wrapping or wringing out before the concentric contraction. If the pain is more at the medial insertion point, check for a higher rate of pronation during contactReduce the DF angle – increase cadence Stretching ?? At end range getting tendon wringing out – increased compression.

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Posterior Tibial Tendon Dysfunction

Runs from deep posterior compartment of the leg to insert at the navicular, middle cuneiform, second through fourth metatarsals

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Posterior Tibialis Tendon

Functions as a shock absorber at heel strike,

invertor

of the foot, functions eccentrically from heel strike to

midstance

where it helps stabilize the foot, and aids in force generation at heel lift and toe off

Usually a slow progressive presentation

Swelling and tenderness are commonly present. Need to palpate/inspect the proximal aspect of the muscle

Pain and or weakness with resisted inversion of a plantar flexed foot

(Kindred J, et al 2011 Current Sports Medicine Reports)

(

Tenforde

A, et al 2016 Phys Med

Rehabil

Clin

N Am)

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Posterior Tibialis

Difficulty with ability to do a heel rise. Also check as the foot goes into plantar flexion, does the

calcaneus

invert (if functioning correctly) or does the heel stay in

valgus

Has been broken down into a 3 stages, with the more typical presentation in running at the first stage, synovial inflammation within the sheath and/or

paratendon

.

(Pelletier-

Galarneau

M, et al. 2015 Am J

Nucl

Med Mol Imaging)

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Posterior Tibialis Treatment

Acute: activity modification, potentially with a walking boot, and relative rest. Ice, NSAID’s or iontophoresis.Strengthening of PF’s Foot orthosis/tapingInjections?

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Plantar Fascitis

Has been reported to be present in about 8% of runners with musculoskeletal problems and has a lifetime

prevalence

of 10%

(Kindred J, et al 2011 Current Sports Medicine Reports)

No clear etiology, but is thought to be mechanical (

Pes

planus

, excessive

pronation

, decreased DF, increased daily WB, and obesity.

Bone spur??

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Plantar Fascitis

Windlass mechanism – with toe DF during heel off pulls the plantar fascia tight, locking the midfoot and attempting to prevent longitudinal arch collapse. Conservative treatment can include stretching, taping, orthotics, strengthening, modalities, night splints (Tenforde A, et al 2016 Phys Med Rehabil Clin N Am)

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Ankle Sprains

Studies have shown that 1/3 of female and ¼ of male high school age runners have a history of an ankle sprain (Tenforde AS, et al)Lateral ankle sprains are the most commonEvaluate the ligamentous structures, check for syndesmotic injury (not as common)

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Ankle Sprains

PRICEReduction of edema and establishing pain free ROMPostural and balance exercisesStrengthening the intrinsic and extrinsic muscles of the foot and ankle as well as proximally.

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Bone Stress Injuries

Metatarsal stress fractures are the second most common stress fracture in athletes and the most common in the foot.

Muscular fatigue with running increases stress to the metatarsals, with the 2

nd

, 3

rd

, and 4

th

metatarsals account for 90% of the fractures

2

nd

is most vulnerable secondary to it’s anatomic rigidity.

(

Bischof

J, et al, 2010 Gait Posture)

(Kennedy JG, et all, 2005 Current Opinion in Pediatrics)

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Stress Fractures

Risk Factors:

Previous bone stress injury

Load applied to the bone – Training and biomechanical issues (loading rate, impact force, braking impulse).

Factors influencing ability of bone to resist load (physical activity history, energy availability, calcium and Vitamin D status.

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Stress Fractures

Metatarsal stress fractures usually occur from a change in running frequency, duration or intensity.

Usually pain is without a specific MOI and early on it is relieved with rest. If running continues, the pain tends to become more consistent throughout ADL’s.

Look for focal tenderness, swelling.

To screen for tendonitis

vs

stress fracture – resist toe extension as this should not be a positive test with a stress fracture.

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Stress Fracture

Risk factors:

Previous bone stress injury

Bone stress – load applied to it. Training errors or biomechanical – loading rate, impact force, and braking impulse.

Factors influencing the ability of bone to resist load (Bone mass and cross sectional area)

Kinematic Predictors: Center of mass to heel distance at initial contact. Angle of inclination at initial contact. Foot inclination angle and step width.

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Biomechanics

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Stress Fractures

Clinical decisions to make in the return to running

Location and severity of the injury

Impact free duration

Any previous running related injuries

Vitamin/Nutrition deficiencies

Running Experience

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3 Phases of Return to Running

Phase one: NWB to beginning weight supported Phase two: Impact preparation for controlling GRF and deceleration drillsPhase three: Impact tolerance, reduction of GRF’s, bounding drills.

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Return to Running

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Nerve Injuries

Neuromas (most commonly between the third and fourth metatarsals). Affects women 10x more than males – most likely because of a more narrow toe box.Presents with pain, tingling numbness to web space.Trials of shoe wear modification or inserts to reduce pressure at MET headsTarsal Tunnel Syndrome – injury to the posterior tibial nerve as it goes below the flexor retinaculum on the medial side of the ankle. Does not like to be compressed and often times seen in runners who run barefoot or in minimalist shoes. (Ferkel E, et al 2015 Clin Sports Med)

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Tarsal Tunnel

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Tarsal Tunnel

Tarsal Tunnel contains: posterior

tibial

nerve, posterior

tibialis

, flexor

hallucis

longus

, flexor

digitorum

longus

, posterior

tibial

artery/vein.

Symptoms: burning, tingling and shooting pain along the heel and medial aspect of ankle. Symptoms increase with standing, walking, running.

Ankle instability can be a contributing factor.

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Running Shoes

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Shoes

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Running Mechanics

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Conclusion

Thank You!

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References

Kindred J,

Trubey

C, Simons S. Foot injuries in runners. Current Sports Medicine Reports. 2011; 10(5):249-254.

Tenforde

A, Yin A, Hunt K. Foot and ankle injuries in runners. Phys Med

Rehabil

Clin

N Am. 2016; 27:121-137.

Rabin A,

Kozol

Z,

Finestone

A. Limited ankle

dorsiflexion

increases the risk for mid portion

achilles

tendinopathy

in infantry recruits: a prospective cohort study. J Foot Ankle Research. 2014; 7:48.

Azevedo

L, Lambert M, Vaughn C, O’Connor C,

Schwellnus

M. Biomechanical variables associated with Achilles

tendinopathy

in runners. Br J Sports Med. 2009;43:288-292.

Creaby

M, Honeywell C,

Franettovich

M,

Schache

A,

Crossley

K. Hip biomechanics are altered in male runners with

achilles

tendinopathy

. Med

Sci

Sport and Exercise. 2016;549-554.

Kim S, Yu J. Changes of gait parameters and lower limb dynamics in recreational runners with

achilles

tendinopathy

. J Sports Science and Medicine. 2015; 14:284-289.

Agresta

C, Brown A. Gait retraining for injured and healthy runners using augmented feedback: a systematic literature review. JOSPT. 2015; 45(8):576-585.

Smith M, Honeywell C,

Wyndow

N,

Crossley

K,

Creaby

M.

Neuromotor

control of

gluteal

muscles in runners with

achilles

tendinopathy

. Med and Science in Sports and Exercise. 2014; 594-599.

Yu J. Comparison of lower limb muscle activity during eccentric and concentric exercises in runners with

achilles

tendinopathy

. J Phys

Ther

Sci. 2014; 26:1351-1353.

Matias

A,

Taddei

U, Duarte M, Sacco I. Protocol for evaluating the effects of a therapeutic foot exercise program on injury incidence, foot functionality and biomechanics in long-distance runners: a randomized controlled trial. BMC Musculoskeletal Disorders. 2016;17:160.

Warden S, Davis I,

Fredericson

M. Management and prevention of bone stress injuries in long distance runners. JOSPT. 2014;44(10):749-765.

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References

Ferkel

E, Davis W, Ellington J. Entrapment neuropathies of the foot and ankle.

Clin

Sports Med. 2015; 34:791-801.

Nielson R,

Buist

I,

Parner

E,

Nohr

E, Sorenson H, Rasmussen. Foot

pronation

is not associated with increased injury risk in novice runners wearing a neutral shoe: a 1 year prospective cohort study. Br J Sports Med. 2014; 48:440-447.

Kennedy J, Knowles B, Dolan M,

Bohne

W. Foot and ankle injuries in the adolescent runner. Current Opinion in Pediatrics. 2005; 17:34-42.

Worp

M,

Wijer

A,

Staal

J,

Nijhuis

-van

der

Sanden M. Reproducibility of and sex differences in common

orthopaedic

ankle and foot tests in runners. BMC Musculoskeletal Disorders. 2014; 15:171.

Barnes R, Smith P. The role of footwear in minimizing lower limb injury. J Sports Sci. 1994; 12:341-353.

Bishop M, et al. Athletic footwear, leg stiffness, and running kinematics. J

Athl

Train. 2006; 41:387-392.

Kurz

M,

Stergiou

N. The spanning set indicates that variability during the stance period of running is affected by footwear. Gait Posture. 2003; 17:132-135.