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Clinical Testing and Treatment of Running Injuries

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Jennifer Reiner

on 24 May 2018

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Transcript of Clinical Testing and Treatment of Running Injuries

Clinically Applied Biomechanics, Assessment, and Treatment of Running Injuries
Seated Hip ER
Hip Abductors
Glute med vs TFL
Eccentric HS Test
Shoe Choice
**no evidence that shoes based on foot shape rather than a standard running shoe significantly reduced rate of running injuries (Yeung 2011)

Softer Shoe
6. Drop Vertical Jump Tasks
Frontal plane control
Should be symmetrical
Avg normal 7-13 female 3-8male
PRI Examination
Adduction Drop Test

Treadmill Feedback
1. Leg length
Functional vs Structural

Auditory cues
Cuing - run like you're running on eggshells
Cadence Manipulation

Cuing - land w/ foot underneath you
Indirectly by changing cadence - 90 steps (180 contacts) per min
Favorite songs BPM (songbpm.com or jog.fm)

Order of Operations
*Previous Injury
Running level
Distance and frequency
Recent changes in training or frequency
Strength train, biking, etc
Number of races per year
Hilly course
Trail running

Muscle Strength Tests:
SI Joint Mobility
Proximal/Distal Tib-Fib
Patellar Mobility
Talocrural Glides
Joint Mobility and Palpation
2. Q angle dynamic
Video analysis of functional test
Flexibility Measures
1. KEA (popliteal angle)
15-20 degrees from full extension
2. Craig's Test
Prone hip IR comparison
3. Ely's/Thomas Test
5. Single Leg Squat
Frontal and transverse plane
Mimics unilateral stance phase of running
4. Runners Pose Stability and Balance
Eyes open/closed
Avg hip angle 50-80
20 sec
7. Single Leg Step Down and Drop Jump
Medial collapse easier to see in SL
3. Overhead Squat
Hip Abduction/ER
Hip Abductors
Glute med vs TFL
Supine Hip Extension
2. Core Assessment: Double Leg Lowering
36 degrees females
15 degrees males
Knee Window
Pelvic Drop
Functional Taping
SERF Strap
Heel Whips
1. TC mobilization

Obliquity of Pelvis
Muscle shortening/lengthening
Length-tension relationship
Increased tone/Trigger points
Arthrokinematics (glides/wobbles)
Osteokinematics (bends)
2. Rearfoot Mobilization
1. MFD/ART lateral hip musculature
2. SFMA 4x4
3. DNS - Baby Get Up
Tubing and dynamic variations
4. Open/Closed chain hip IR/ER
Flexibility/Mobility Issues
Decr dorsiflexion
Decr hip mobility (anti-retro)
Hamstring length
*Confirm w/ exam
Must address both neuromuscular training and strength (Olson 2010, Willy 2011)
Strength - side plank, baby get up
Neuromuscular re-ed - runner's pose lateral/wall drill, visual feedback (mirror)
Side shuffle, skipping backwards, carioca
1. Strength
Eccentric lowering from deficit
75 heel raises from deficit for return to sport (marathon)
2. Plyo
Tape hop forward, backward
Tape hop lateral
Multiplanar hop exercises
Core Stability
Improving GRF
Jenn Reiner, DC, CSCS, ART
twitter: @drjreiner

Etiology and pathomechanics that lead to running injuries

Introduction to video analysis

Modifications to running technique based on video

Assessment of musculoskeletal system with correlation to video analysis

Treatment plan based on assessment and video analysis
Running Injuries
What % of runners training for a marathon get injured?

What % of all runners have injuries?

What part of the body is injured the most?
UCSF, PCCW, and You!
Extrinsic Factors
1. Previous Injury 2.7x (Buist 2010)

2. More than 6 running events per year

3. 16 years and older

4. High running volume (>40 miles/week)

5. Rapid change in volume

6. BMI >30 (for novice runners)
Intrinsic Risk Factors
1. Weakness of hip musculature (abduction and ER)
(Niemuth 2005, Fredericson 2000)

2. Increased Hip IR during stance
Protective Factors
Higher education (Van Middel Koop 2008)

Running <40m/wk

Interval Training

Ramping training volume and pace

BMI <20 (Nielson 2013)
Biomechanics and Injury
Understanding Biomechanics
Greater subtalar eversion during midstance of running

Limited subtalar eversion with compensatory pronation

Ankle/Foot Mobility

Ankle instability

Lower plantar flexor eccentric strength (Mahieu 2006)

Phasic timing of soleus firing relative to lateral/medial gastroc (Wyndow 2013)
Risk Factors
for Ankle/Foot Injuries
Mechanical Contributions
Risk Factors
for knee Injury
Mechanical Contributions
Previous Foot/Ankle Considerations

Dynamic Q Angle

Poor proximal control (lumbopelvic and pelvis on femur)
Pelvic drop
Femoral Adduction/Internal Rotation

Controlling Ground Reaction Forces
Video Analysis
Two Views
Marker Placement
Bottom of heel b/l Lateral knee joint
Top of shoe b/l Greater trochanter
Lateral malleolus ASIS b/l
Head of 5th met head PSIS b/l
Mid calf b/l C7
15 Markers
Lateral View
1. Foot strike (heel, midfoot, forefoot)

2. Dorsiflexion angle (<15 degrees ideal)

3. Knee flexion during stance (<40=too stiff)

Lateral View
4. Peak hip extension (Line from greater trochanter to lateral knee joint and vertical line)

5. Tibia/Shank position at impact

6. Overstride (line from heel of shoe perpendicular to ground)
Posterior View
1. Foot flare at stance

2. Rearfoot

3. Heel whips

Posterior View
5. Pelvic Drop - draw line from stance leg PSIS marker parallel to floor; second marker must not drop below

6. Lateral shift - vertical line between PSIS; C7 marker should intersect
4. Frontal plane projection angle
1. Orthopedic Evaluation
a. Anthropmetric
b. Mobility/Flexibility
c. Orthos
2. Chiro
4. DNS
5. PRI
6. Functional to Running
Selective Functional Movement Assessment

Systematic approach
Break down of dysfunctional patterns to into software/ hardware problems


Position not considered
Breathing not considered
Functional tests for running not considered
L and R will never be symmetrical
Pull is biomeachnically and neurologically to R side of body
Nervous System
Immediate Feedback
Global movement
Joint assessment
Pattern does not fit







All the above

Working knowledge of motor development
Motor patterning
Intrinsic locomotor system stabilization


Position not considered
Transferability difficult
Lack of a system

Important Tests for Runners
Muscle Tests
1. Hip abduction and ER
2. Calf raises
3. Hip Extension Test
4. Eccentric Hamstring Test
5. Seated Hip ER/IR
1. Seated and Prone Hip ER/IR
2. Closed Chain Dorsiflexion
3. TKE Angle

Joint Mobility Test
1. GTE
2. Forefoot, Midfoot, Rearfoot/Subtalar
3. Talocrural Joint
4. Fibula
5. SI Joint
Joint by joint approach assessing mobility and stability
Developmental Kinesiology
Science of Asymmetry
Hopper 2005 KEA better than SLR and at 24 hrs after treatment in I.D changes
Davis 2008 KEA good to excellent intratester reliability, and better validity
Gajdosik 1993 Active KEA better than PKE for functional length
Glute med vs TFL
Calf Raises

1. Functional Dorsiflexion
Start at 4 inches from wall (tape measure)
U-clinometer (36 and 42)
(Astrom, Arvidson
Muscle Imbalance/Motor Control
Proximal musculature (hip/core)
Hamstring (lat vs med)
Neuromuscular Training
Sport Transferable
Hip Mobility
Subelite marathon and 1/2 marathon
90% rearfoot, 3% midfoot, 2% forefoot
Elite marathon
94% rearfoot, 6% mid and forefoot
Elite 1/2 marathon
75% rearfoot, 24% midfoot, 1%forefoot
Endurance barefoot
72% rearfoot, 24%midfoot, 4% forefoot
Foot Strike Pattern
Knee 50%
Foot 40%
Thigh 38%
Leg 32%
Ankle 17%
Hip/Pelvis 11%
(Van Gent 2007)
It's not about strike pattern that determines high impact vs low. It's many variables including mechanics (cadence).
Study looking at FFS and RFS, both overstride and then good stride. Loading rates were similar
Great improvement in decreasing GRF just by altering stride length
(Edwards et al, 2009)
Kolar P, Sulc J, Kyncl M, Sanda J, Cakrt O, Andel R, Kumagai K, Kobesova A.
Postural Function of the Diaphragm in Persons With and Without Chronic Low Back Pain. , J Orthop Sports Phys Ther, 2012;42:352-362,
Subtalar Mobility
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