Comprehensive functional evaluation of the injured runner

Clinical and exercise professional opinion of return-to-running readiness after childbirth: an international Delphi study and consensus statement

Female athletes have identified a lack of guidance as a barrier to successfully returning to running postpartum, and existing guidelines are vague. Our aim was to define the current practice of determining postpartum run-readiness through a consensus survey of international clinicians and exercise professionals in postpartum exercise to assist clinicians and inform sport policy changes.A three-round Delphi approach was used to gain international consensus from clinicians and exercise professionals on run-readiness postpartum. Professionals who work with postpartum runners participated in an online survey to answer open-ended questions about the following postpartum return-to-running topics: definitions (runner and postpartum), key biopsychosocial milestones that runners need to meet, recommended screening, timeline to initiate running, support items, education topics and factors that contribute to advising against running. Consensus was defined as ≥75% participant agreement.One hundred and eighteen professionals participated in round I, 107 participated in round II (response rate 90.6%) and 95 participated in round III (response rate 80.5%). Responses indicated that, following a minimum 3-week period of rest and recovery, an individualised timeline and gradual return to running progression can be considered. Screening for medical and psychological concerns, current physical capacity, and prior training history is recommended prior to a return to running.This study proposes recommendations for the initial guidance on return-to-running postpartum, framed in the context of current research and consensus from professionals. Future research is needed to strengthen and validate specific recommendations and develop guidelines for best practice when returning-to-running after childbirth.

Clinical Indoor Running Gait Analysis May Not Approximate Outdoor Running Gait Based on Novel Drone Technology

BACKGROUND

Traditional running gait analysis is limited to artificial environments, but whether treadmill running approximates overground running is debated. This study aimed to compare treadmill gait analysis using fixed video with outdoor gait analysis using drone video capture.

HYPOTHESIS

Measured kinematics would be similar between natural outdoor running and traditional treadmill gait analysis.

STUDY DESIGN

Crossover study.

LEVEL OF EVIDENCE

Level 2.

METHODS

The study population included cross-country, track and field, and recreational athletes with current running mileage of at least 15 km per week. Participants completed segments in indoor and outdoor environments. Indoor running was completed on a treadmill with static video capture, and outdoor segments were obtained via drone on an outdoor track. Three reviewers independently performed clinical gait analysis on footage for 32 runners using kinematic measurements with published acceptable intra- and interrater reliability.

RESULTS

Of the 8 kinematic variables measured, 2 were found to have moderate agreement indoor versus outdoor, while 6 had fair to poor agreement. Foot strike at initial contact and rearfoot position at midstance had moderate agreement indoor versus outdoor, with a kappa of 0.54 and 0.49, respectively. The remaining variables: tibial inclination at initial contact, knee flexion angle initial contact, forward trunk lean full gait cycle, knee center position midstance, knee separation midstance, and lateral pelvic drop at midstance were found to have fair to poor agreement, ranging from 0.21 to 0.36.

CONCLUSION

This study suggests that kinematics may differ between natural outdoor running and traditional treadmill gait analysis.

CLINICAL RELEVANCE

Providing recommendations for altering gait based on treadmill gait analysis may prove to be harmful if treadmill analysis does not approximate natural running environments. Drone technology could provide advancement in clinical running recommendations by capturing runners in natural environments.

Snapping Hip Syndrome: A Comprehensive Update

Purpose of review

This is a comprehensive literature review regarding the pathogenesis, diagnosis, and treatment of snapping hip syndrome (SHS). It covers the diverse etiology of the syndrome and management steps from conservative to more advanced surgical techniques.

Recent Findings

Recent advances in imaging modalities may help in diagnosing and treating SHS. Additionally, arthroscopic procedures can prove beneficial in treating recalcitrant cases of SHS and have recently gained popularity due to their non-invasive nature.

Summary

SHS presents as an audible snap due to anatomical structures in the medial thigh compartment and hip. While often asymptomatic, in some instances, the snap is associated with pain. Its etiology can be broadly classified between external SHS and internal SHS, which involve different structures but share similar management strategies. The etiology can be differentiated by imaging and physical exam maneuvers. Treatment is recommended for symptomatic SHS and begins conservatively with physical therapy, rest, and anti-inflammatory medications. Most cases resolve after 6-12 months of conservative management. However, arthroscopic procedures or open surgical management may be indicated for those with persistent pain and symptoms. Different surgical approaches are recommended when treating internal SHS vs. external SHS. Due to advancements in treatment options, symptomatic SHS commonly becomes asymptomatic following intervention.

Athletes with a clinical rating of good and poor lumbopelvic stability have different kinematic variables during single leg squat and dip test

OBJECTIVES

To examine the kinematics of athletes with good and poor lumbopelvic stability (LPS) based on clinical rating criteria of single leg squat (SLS) and dip test (DT) The aim was to establish if good and poor LPS categorization is supported by differences in kinematic variables.

METHODS

Sixty-two recreational athletes had their LPS categorized using clinical rating criteria for SLS and DT as good, poor or neither good nor poor. Kinematic measures were examined in those with good (N = 8) or poor (N = 14) LPS and results compared to the rating criteria.

RESULTS

Multiple clinical rating criteria for good and poor LPS groups were distinguished by kinematic measures. Smoothness of motion for both SLS and DT distinguished good and poor LPS. Minimal (good) or discernible movement (poor) out of the starting plane was confirmed with kinematic measures. For SLS these movements were: weight-bearing hip adduction, non-weightbearing hip abduction, pelvic rotation, and trunk sideflexion, and for DT: weightbearing hip adduction, non-weightbearing hip abduction and pelvic obliquity. Additionally, hip dissociation (SLS) distinguished good and poor LPS.

CONCLUSION

Athletes with good and poor LPS have different kinematic measures in single leg squat and dip test. Multiple clinical rating criteria of LPS that distinguish good and poor stability were confirmed by kinematic measures.

Do alterations in muscle strength, flexibility, range of motion, and alignment predict lower extremity injury in runners: a systematic review

Background

Injury is common in running and seen to impact up to 94% of recreational runners. Clinicians often use alterations from normal musculoskeletal clinical assessments to assess for risk of injury, but it is unclear if these assessments are associated with future injury.

Objectives

To identify alterations in muscle strength, flexibility, range of motion, and alignment that may predict lower extremity injury in runners.

Methods

Articles were selected following a comprehensive search of PubMed, Embase, CINAHL, and SPORTDiscus from database inception to May 2018. Included articles were prospective cohort studies, which specifically analyzed musculoskeletal impairments associated with future running-related injury. Two authors extracted study data, assessed the methodological quality of each study using the Critical Appraisal Tool and assessed the overall quality using the GRADE approach.

Results

Seven articles met the inclusion criteria. There was very low quality of evidence for the 7 identified clinical assessment alteration categories. Strong hip abductors were significantly associated with running-related injury in one study. Increased hip external-to-internal rotation strength and decreased hip internal range of motion were protective for running injury, each in one study. Decreased navicular drop in females had a protective effect for running-related injury in one study.

Conclusions

Due to very low quality of evidence for each assessment, confounders present within the studies, a limited number of studies, different measurement methods among studies, measurement variability within clinical assessments, inconsistent definitions of injury and runner, different statistical modeling, and study bias, caution is suggested in interpreting these results.

Is Hip Abduction Strength Asymmetry Present in Female Runners in the Early Stages of Patellofemoral Pain Syndrome?

BACKGROUND

The current literature indicates that hip abduction weakness in female patients is associated with ipsilateral patellofemoral pain syndrome (PFPS) as part of the weaker hip abductor complex. Thus, it has been suggested that clinicians should consider screening female athletes for hip strength asymmetry to identify those at risk of developing PFPS to prevent the condition. However, no study to date has demonstrated that hip strength asymmetry exists in the early stages of PFPS.

PURPOSE

To determine whether hip abduction strength asymmetry exists in female runners with early unilateral PFPS, defined as symptoms of PFPS not significant enough to cause patients to seek medical attention or prevent them from running at least 10 miles per week.

STUDY DESIGN

Controlled laboratory study.

METHODS

This study consisted of 21 female runners (mean age, 30.5 years; range, 18-45 years) with early unilateral PFPS, who had not yet sought medical care and who were able to run at least 10 miles per week, and 36 healthy controls comparably balanced for age, height, weight, and weekly running mileage (mean, 18.5 mi/wk). Study volunteers were recruited using flyers and from various local running events in the metropolitan area. Bilateral hip abduction strength in both a neutral and extended hip position was measured using a handheld dynamometer in each participant by an examiner blinded to group assignment.

RESULTS

Patients with early unilateral PFPS demonstrated no significant side-to-side difference in hip abduction strength, according to the Hip Strength Asymmetry Index, in both a neutral (mean, 83.5 ± 10.2; P = .2272) and extended hip position (mean, 96.3 ± 21.9; P = .6671) compared with controls (mean, 87.0 ± 8.3 [P = .2272] and 96.6 ± 16.2 [P = .6671], respectively). Hip abduction strength of the affected limb in patients with early unilateral PFPS (mean, 9.9 ± 2.2; P = .0305) was significantly stronger than that of the weaker limb of control participants (mean, 8.9 ± 1.4; P = .0305) when testing strength in a neutral hip position; however, no significant difference was found when testing the hip in an extended position (mean, 7.0 ± 1.4 [P = .1406] and 6.6 ± 1.5 [P =.1406], respectively).

CONCLUSION

The study data show that early stages of unilateral PFPS in female runners is not associated with hip abduction strength asymmetry and that hip abduction strength tested in neutral is significantly greater in the affected limb in the early stages of PFPS compared with the unaffected limb. However, when tested in extension, no difference exists. Further studies investigating the early stages of PFPS are warranted.

CLINICAL RELEVANCE

Unlike patients with PFPS seeking medical care, early PFPS does not appear to be significantly associated with hip abduction strength asymmetry.

The injured runner

Running is often recommended by physicians to maintain a healthy lifestyle. As more individuals participate in running-related activities, clinicians must be increasingly aware of common injuries. Training errors leading to overuse are the most common underlying factors in most running-related injuries. Clinicians need to keep in mind that the presenting injury is frequently the result of an inability to compensate for a primary dysfunction at another site. Although imaging may be helpful in differentiating among diagnoses with similar clinical presentations, a detailed history and physical examination are essential in making a correct diagnosis.

The running athlete: stress fractures, osteitis pubis, and snapping hips

CONTEXT

Pelvic stress fractures, osteitis pubis, and snapping hip syndrome account for a portion of the overuse injuries that can occur in the running athlete.

EVIDENCE ACQUISITION

PUBMED SEARCHES WERE PERFORMED FOR EACH ENTITY USING THE FOLLOWING KEYWORDS: snapping hip syndrome, coxa sultans, pelvic stress fracture, and osteitis pubis from 2008 to 2013. Topic reviews, case reports, case series, and randomized trials were included for review.

STUDY DESIGN

Clinical review.

LEVEL OF EVIDENCE

Level 4.

RESULTS

Collectively, 188 articles were identified. Of these, 58 were included in this review.

CONCLUSION

Based on the available evidence, the majority of these overuse injuries can be managed non-operatively. Primary treatment should include removal from offending activity, normalizing regional muscle strength/length imbalances and nutritional deficiencies, and mitigating training errors through proper education of the athlete and training staff.

STRENGTH OF RECOMMENDATION TAXONOMY

C.

Evaluation and treatment of biking and running injuries

Exercise is universally recognized as a key feature for maintaining good health. Likewise, lack of physical activity is a major risk factor for chronic disease and disability, an especially important fact considering our rapidly aging population. Biking and running are frequently recommended as forms of exercise. As more individuals participate in running-related and cycling-related activities, physicians must be increasingly aware of the common injuries encountered in these pursuits. This review focuses on the evaluation and management of common running-related and cycling-related injuries.

Iliotibial band syndrome in runners: a systematic review

BACKGROUND

The popularity of running is still growing and, as participation increases, the incidence of running-related injuries will also rise. Iliotibial band syndrome (ITBS) is the most common injury of the lateral side of the knee in runners, with an incidence estimated to be between 5% and 14%. In order to facilitate the evidence-based management of ITBS in runners, more needs to be learned about the aetiology, diagnosis and treatment of this injury.

OBJECTIVE

This article provides a systematic review of the literature on the aetiology, diagnosis and treatment of ITBS in runners.

SEARCH STRATEGY

The Cochrane Library, MEDLINE, EMBASE, CINAHL, Web of Science, and reference lists were searched for relevant articles.

SELECTION CRITERIA

Systematic reviews, clinical trials or observational studies involving adult runners (>18 years) that focused on the aetiology, diagnosis and/or treatment of ITBS were included and articles not written in English, French, German or Dutch were excluded.

DATA COLLECTION AND ANALYSIS

Two reviewers independently screened search results, assessed methodological quality and extracted data. The sum of all positive ratings divided by the maximum score was the percentage quality score (QS). Only studies with a QS higher than 60% were included in the analysis. The following data were extracted: study design; number and characteristics of participants; diagnostic criteria for ITBS; exposure/treatment characteristics; analyses/outcome variables of the study; and setting and theoretical perspective on ITBS.

MAIN RESULTS

The studies of the aetiology of ITBS in runners provide limited or conflicting evidence and it is not clear whether hip abductor weakness has a major role in ITBS. The kinetics and kinematics of the hip, knee and/or ankle/foot appear to be considerably different in runners with ITBS to those without. The biomechanical studies involved small samples, and data seem to have been influenced by sex, height and weight of participants. Although most studies monitored the management of ITBS using clinical tests, these tests have not been validated for this patient group. While the articles were inconsistent regarding the treatment of ITBS, hip/knee coordination and running style appear to be key factors in the treatment of ITBS. Runners might also benefit from mobilization, exercises to strengthen the hip, and advice about running shoes and running surface.

CONCLUSION

The methodological quality of research into the management of ITBS in runners is poor and the results are highly conflicting. Therefore, the study designs should be improved to prevent selection bias and to increase the generalizability of findings.

Common leg injuries of long-distance runners: anatomical and biomechanical approach

CONTEXT

Long-distance running (greater than 3000 m) is often recommended to maintain a healthy lifestyle. Running injury rates increase significantly when weekly mileage extends beyond 40 miles cumulatively. With the development of running analysis and other diagnostic tests, injuries to the leg secondary to bone, musculotendinous, and vascular causes can be diagnosed and successfully managed.

EVIDENCE ACQUISITION

Searches used the terms running, injuries, lower extremity, leg, medial tibial stress syndrome, compartment syndrome, stress fractures, popliteal artery entrapment, gastrocnemius soleus tears, and Achilles tendinopathy. Sources included Medline, Google Scholar, and Ovid from 1970 through January 2012.

RESULTS

Tibial stress fractures and medial tibial stress syndrome can sometimes be prevented and/or treated by correcting biomechanical abnormalities. Exertional compartment syndrome and popliteal artery entrapment syndrome are caused by anatomic abnormalities and are difficult to treat without surgical correction.

CONCLUSION

Leg pain due to bone, musculotendinous, and vascular causes is common among long-distance runners. Knowledge of the underlying biomechanical and/or anatomic abnormality is necessary to successfully treat these conditions.

Evaluation of the injured runner

Leg pain in runners is a common complaint in any sports medicine practice. Although the possible diagnoses are many, the evaluation depends on a thorough history. A comprehensive physical examination should include not only examination of the injury but the kinetic chain and core. It is imperative to recognize functional deficiencies in core strength and balance to prevent further injury. The successful integration of history, physical examination, and functional testing will enhance your evaluation of the injured runner and help return athletes to sport.

Development of clinical rating criteria for tests of lumbopelvic stability

Background. Lumbopelvic stability (LPS) is regarded as important for injury prevention, yet there are few reliable or valid tests that can be used in the clinical assessment of LPS. Three dynamic functional tests were identified that assess LPS in multiple planes of motion: dip test (DT), single leg squat (SLS), and runner pose test (RPT). Existing rating criteria for SLS have limited reliability and rating criteria for DT and RPT have not been established. Objective. To develop rating criteria for three clinical tests of LPS. Design. Qualitative research: focus group. Method. A focus group of five expert physiotherapists used qualitative methods to develop rating criteria for the three clinical tests. Results. Detailed rating criteria were established for the three tests. Each key factor considered important for LPS had characteristics described that represented both good and poor LPS. Conclusion. This study established rating criteria that may be used to clinically assess LPS.

The anatomy and biomechanics of running

To understand the normal series of biomechanical events of running, a comparative assessment to walking is helpful. Closed kinetic chain through the lower extremities, control of the lumbopelvic mechanism, and overall symmetry of movement has been described well enough that deviations from normal movement can now be associated with specific overuse injuries experienced by runners. This information in combination with a history of the runner's errors in their training program will lead to a more comprehensive treatment and prevention plan for related injuries.

Successful rehabilitation of a recreational endurance runner: initial validation for the Bunkie test

This case report details the musculoskeletal evaluation and the successful rehabilitation of a 24-year-old female recreational distance runner who self-referred to physical therapy with an acute bout of low back pain (LBP). Her LBP was provoked during each distance run. The patient's musculoskeletal evaluation revealed core weakness, especially on the left. A recently reported functional test, the Bunkie test, was administered as part of the physical evaluation. The scores from the Bunkie test correlated with other quantitative and qualitative findings. A therapeutic exercise program emphasizing core stabilization was prescribed. The patient was able to shortly return to running pain-free.

Medial tibial stress syndrome: conservative treatment options

Medial tibial stress syndrome (MTSS), commonly known as “shin splints,” is a frequent injury of the lower extremity and one of the most common causes of exertional leg pain in athletes (Willems T, Med Sci Sports Exerc 39(2):330–339, 2007; Korkola M, Amendola A, Phys Sportsmed 29(6):35–50, 2001; Hreljac A, Med Sci Sports Exerc 36(5):845–849, 2004). Although often not serious, it can be quite disabling and progress to more serious complications if not treated properly. Often, the cause of MTSS is multi-factorial and involves training errors and various biomechanical abnormalities. Few advances have been made in the treatment of MTSS over the last few decades. Current treatment options are mostly based on expert opinion and clinical experience. The purpose of this article is to review published literature regarding conservative treatment options for MTSS and provide recommendations for sports medicine clinicians for improved treatment and patient outcomes.

A return to running program for the postpartum client: a case report

The purpose of this case report is to present a return to running program for a postpartum client who had delivered via cesarean section. The client, a 29-year-old female health care professional who was 8 months postcesarean section, was referred to physical therapy for a return to running exercise program. The client had three live births during a 30-month time period (February 2004 to August 2006). During her last labor she underwent an emergency cesarean section because of a low fetal heart rate. Since her surgery the client had not participated in an exercise routine. Following an 8-week training program the client was able to demonstrate both quantitative and qualitative functional improvements, including running a 12-minute mile. This case describes a successful return to running program for a postpartum client who delivered her child via cesarean section. Future research is warranted to determine the optimal evaluation strategy and exercise training programs for this population.

Management of common running injuries

Runners are susceptible to a variety of potential injuries because of the considerable stress of this activity. This can create a challenge for the treating practitioner; however, many of the common ailments occur in a reasonably predictable pattern. A careful history and physical examination are necessary for accurate diagnosis. Having a good understanding of these injuries as well of the role of biomechanical factors and common training errors can assist with appropriate care. Further development in the knowledge of soft tissue trauma, gait, and diagnostic and therapeutic modalities should lead to improved management of the injuries facing these athletes.