Pain In Runners Research Articles

Shoddy Journalism Promoted Premature Advice About the Prevention of Back Pain in Runners

Shoddy Journalism Promoted Premature Advice About the Prevention of Back Pain in Runners

Differences in Knee and Hip Adduction and Hip Muscle Activation in Runners With and Without Iliotibial Band Syndrome

BackgroundIliotibial band syndrome has been associated with altered hip and knee kinematics in runners. Previous studies have recommended further research on neuromuscular factors at the hip. The frontal plane hip muscles have been a strong focus in strength comparison but not for electromyography investigation. ObjectiveTo compare hip surface electromyography, and frontal plane hip and knee kinematics, in runners with and without iliotibial band syndrome. DesignObservational cross-sectional study. SettingBiomechanics research laboratory within a university. ParticipantsThirty subjects were recruited consisting of 15 injured runners with iliotibial band syndrome and 15 gender-, age-, and body mass index–matched controls. In each group, 8 were male runners and 7 were female runners. Inclusion criteria for the injured group were pain within 2 months related to iliotibial band syndrome and a positive Noble compression test. Participants were excluded if they reported other lower extremity diagnoses within the last year or active lower extremity or low back pain not related to iliotibial band syndrome. Controls were excluded if they reported a history of iliotibial band syndrome. Convenience sampling was used based on referrals from local running clinics and orthopedic clinics. MethodsThree-dimensional motion capture was performed with 10 high-speed cameras synchronized with wireless surface electromyography during a 30-minute run. The first data point was at 3 minutes, using a constant speed of 2.74 meters per second. A second data point was at 30 minutes, using a self-selected pace by the participant to allow for a challenging run until completion at 30 minutes. Main Outcome MeasurementsMotion capture was reported as peak kinematic values from heel strike to peak knee flexion for hip adduction and knee adduction. Surface electromyography was reported as a percentage of maximal voluntary contraction for the gluteus maximus, gluteus medius and tensor fascia latae muscles. ResultsInjured runners demonstrated increased knee adduction compared with control runners at 30 minutes (P = .002, control = –1.48°, injured = 3.74°). Tensor fasciae latae muscle activation in injured runners was increased compared with control runners at 3 minutes (P = .017, control = 7% maximal voluntary isometric contraction, injured = 11% maximal voluntary isometric contraction). ConclusionThe results of this study suggest that lateral knee pain in runners localized to the distal iliotibial band is associated with increased knee adduction at 30 minutes. Increased tensor fasciae latae muscle activation at 3 minutes is noted, but more investigation is needed to better understand the clinical meaning. These findings are consistent with but not conclusive evidence supporting the theory that neuromuscular factors of the hip muscles may contribute to increased knee adduction in runners with iliotibial band syndrome. We advise caution using these findings to support treatments intended to modify tensor fasciae latae activation, given the small differences of 4% in muscle activation. Increased knee adduction in runners at 30 minutes was over 5° and beyond the minimal detectable difference. Additional research is needed to confirm whether the degree of knee adduction changes earlier versus later in a run and whether fatigue is a clinically relevant factor. Level of EvidenceIII

Sports Physical Therapy Section Poster Presentations (Abstracts SPO1-SPO166).

These abstracts are presented here as prepared by the authors. The accuracy and content of each abstract remain the responsibility of the authors. In the identification number above each abstract, SPO designates a Sports Physical Therapy Section poster presentation. J Orthop Sports Phys Ther 2018;48(1):A203-A276. doi:10.2519/jospt.2018.48.1.A203.

Iliotibial Band Lengthening: An Arthroscopic Surgical Technique

Iliotibial (IT) band syndrome is a common cause of lateral knee pain in runners and cyclists. Many can be treated nonoperatively; however, some may require surgical lengthening of their IT band to achieve optimal pain relief and a return to preinjury level of activity. Several studies have been published detailing surgical lengthening procedures and satisfactory outcomes after these procedures. However, it is important to continue to improve on and optimize outcomes. We present our arthroscopic IT band–lengthening procedure.

Risk Factors Associated With Foot Pain In Runners

Risk Factors Associated With Foot Pain In Runners

How Does a Standing Exercise Programme Focusing on Hip-Abduction Strength Affect Anterior Knee Pain in Runners?

<p><strong><em>Outline: </em></strong><em>Anterior Knee Pain (AKP) is the most prevalent injury in running. Growing evidence suggests that hip muscle imbalance plays a role in the development of AKP. Gluteus Medius (GMed) is the main abductor of the hip and also stabilises the pelvis during gait. Studies show that hip-abduction strength is decreased in populations with AKP. This relates to increased hip-adduction, hip internal rotation and knee abduction, which are associated with higher patellofemoral contact pressures. <strong>Objective:</strong> The main aim of this study is to determine whether a standing exercise programme will improve hip-abductor strength. The second aim of the study is to determine whether there will be a decrease in running-related pain after completing a six-week standing exercise programme. </em></p><p><strong><em>Design: </em></strong><em>Within-participant pre-test/post-test comparative trial.</em></p><p><strong><em>Setting:</em></strong><em> The Sport’s Clinic at the Malta Football Association. Ta Qali National Stadium (Malta).</em></p><p><strong><em>Main outcome measures: </em></strong><em>GMed torque was measured using a Biodex® System 3 isokinetic dynamometer as demonstrated by Brent et al (2013). The Numerical Rating Scale was used to measure pain related to running. </em></p><p><strong><em>Results: </em></strong><em>Pre-test torque scores were higher on the affected side. Scores on the affected side improved by 22.81% from a mean baseline average of 96.00Nm/kg to 117.86Nm/kg, (p-value 0.013). Scores on the unaffected side improved by 27.97% from a mean baseline average of 90.14Nm/kg to 115.29Nm/kg (p-value 0.031). Post-test scores were more balanced between limbs. Pain scores decreased from 5.29 as measured on the NRS to 1.00 (p-value 0.000). </em></p><p><strong><em>Conclusion: </em></strong><em>Standing exercises aimed at strengthening the hip-abductors may prove to be a valid intervention for prevention and rehabilitation of AKP. However, better quality studies are needed in order to validate this.</em><em></em></p>

The effect of a running task on muscle shear elastic modulus of posterior lower leg

BackgroundMedial tibial stress syndrome (MTSS) is one of the most common causes of exercise-related leg pain in runners. Because stopping training due to pain from MTSS could decrease the athlete’s competitiveness, it is necessary to construct MTSS prevention and treatment programs. However, the effect of running, which is believed to cause MTSS, on shear elastic modulus of the posterior lower leg is unclear. Therefore, the purpose of this study was to investigate the effect of 30 min of running on shear elastic modulus of the posterior lower leg in healthy subjects.MethodsTwenty healthy males volunteered to participate in this study (age, 20.9 ± 0.6 y; height, 169.6 ± 4.5 cm; weight, 62.6 ± 5.2 kg). The shear elastic modulus of the posterior lower leg was measured using ultrasonic shear wave elastography before and immediately after a 30-min running task.ResultsShear elastic moduli of the flexor digitorum longus and tibialis posterior were significantly increased after 30 min running task. However, there were no significant changes in shear elastic moduli of the lateral gastrocnemius, medial gastrocnemius, peroneus longus and peroneus brevis.ConclusionThe results suggested that the increases in shear elastic moduli of flexor digitorum longus and tibialis posterior after running could be a risk factor for running-related MTSS development.

Using Augmented Feedback to Decrease Patellofemoral Pain in Runners: A Pilot study

Objective: Patellofemoral pain (PFP) is a common injury in running. The cause of patellofemoral pain is multifactorial in nature, which results varied treatment approaches for this disorder. Many studies have examined the effect of using strengthening protocols targeted at subjects’ hip and quadriceps strength. Although these studies have resulted in a reduction in short-term PFP for runners, many continue to experience PFP after undergoing these treatment strategies. A more recent theory regarding the treatment of PFP in runners involves the use of augmented verbal and visual feedback. This treatment strategy involves giving the runner scheduled visual feedback to adapt their running strategies in hopes of reducing their PFP. Much of this research has been done with experienced runners in the age range of 18-22 years old. The purpose of this study was to examine the effects of augmented verbal and real-time visual feedback on patellofemoral pain. The hypothesis was that training with the use of auditory and visual feedback would improve patellofemoral pain in this runner. In clinical practice, auditory and visual feedback to change hip and knee mechanics while running may be used as a treatment strategy for patellofemoral pain.

A Comparitive Study on Effectiveness of Taping with Iontophoresis and Taping alone in Chronic Plantar Fascitis

Background: Plantar fasciitis is a painful condition caused by microtrauma to plantar fascia due to overuse. It is a most common cause of heel pain in runners. Various studies proved taping and Iontophoresis as effective in the treating plantar fasciitis. But there are no studies comparing the combined effect of iontophoresis with taping and taping alone in the treatment of plantar fasciitis. Methods: 50 patients suffering from plantar fasciitis who met the inclusion criteria were selected. The subjects were randomly divided into two groups i.e. Group A and Group B. Group A received taping, iontophoresis with plantar fascia stretching. Group B received taping and plantar fascia stretching. A total of 6 treatment sessions were given on alternate days over a period of two weeks for both the groups. Results: VAS and FFI scores across baseline and post intervention showed a significant improvement statistically in their mean scores between Groups A and B (P<0.05). Between group comparison of VAS and FFI scores, it showed that subject treated with Iontophoresis in combination with taping and plantar fascia stretch (Group A) had significant improvement in VAS and functional ability when compared to subjects treated with taping and plantar fascia stretching alone (Group B). Conclusion: Iontophoresis along with Taping and plantar fascia stretching gave an additional benefit when compared with Taping and plantar fascia stretching alone in reducing pain and improving function in plantar fasciitis.

Altering Knee Abduction Angular Impulse Using Wedged Insoles for Treatment of Patellofemoral Pain in Runners: A Six-Week Randomized Controlled Trial.

ObjectiveDetermine if a change in internal knee abduction angular impulse (KAAI) is related to pain reduction for runners with patellofemoral pain (PFP) by comparing lateral and medial wedge insole interventions, and increased KAAI and decreased KAAI groups.DesignRandomized controlled clinical trial (ClinicalTrials.gov ID# NCT01332110).SettingBiomechanics laboratory and community.PatientsThirty-six runners with physician-diagnosed PFP enrolled in the trial, and 27 were analyzed.InterventionsRunners with PFP were randomly assigned to either an experimental 3 mm lateral wedge or control 6 mm medial wedge group. Participants completed a biomechanical gait analysis to quantify KAAIs with their assigned insole, and then used their assigned insole for six-weeks during their regular runs. Usual pain during running was measured at baseline and at six-week follow-up using a visual analog scale. Statistical tests were performed to identify differences between wedge types, differences between biomechanical response types (i.e. increase or decrease KAAI), as well as predictors of pain reduction.Main Outcome MeasuresPercent change in KAAI relative to neutral, and % change in pain over six weeks.ResultsClinically meaningful reductions in pain (>33%) were measured for both footwear groups; however, no significant differences between footwear groups were found (p = 0.697). When participants were regrouped based on KAAI change (i.e., increase or decrease), again, no significant differences in pain reduction were noted (p = 0.146). Interestingly, when evaluating absolute change in KAAI, a significant relationship between absolute % change in KAAI and % pain reduction was observed (R 2 = 0.21; p = 0.030), after adjusting for baseline pain levels.ConclusionThe greater the absolute % change in KAAI during running, the greater the % reduction in pain over six weeks, regardless of wedge type, and whether KAAIs increased or decreased. Lateral and medial wedge insoles were similar in effectiveness for treatment of PFP.Clinical RelevanceAltering KAAI should be a focus of future PFP research. Lateral wedges should be studied further as an alternative therapy to medial wedges for management of PFP.Trial RegistrationClinicalTrials.gov NCT01332110

Influence of step rate and quadriceps load distribution on patellofemoral cartilage contact pressures during running

Interventions used to treat patellofemoral pain in runners are often designed to alter patellofemoral mechanics. This study used a computational model to investigate the influence of two interventions, step rate manipulation and quadriceps strengthening, on patellofemoral contact pressures during running. Running mechanics were analyzed using a lower extremity musculoskeletal model that included a knee with six degree-of-freedom tibiofemoral and patellofemoral joints. An elastic foundation model was used to compute articular contact pressures. The lower extremity model was scaled to anthropometric dimensions of 22 healthy adults, who ran on an instrumented treadmill at 90%, 100% and 110% of their preferred step rate. Numerical optimization was then used to predict the muscle forces, secondary tibiofemoral kinematics and all patellofemoral kinematics that would generate the measured primary hip, knee and ankle joint accelerations. Mean and peak patella contact pressures reached 5.0 and 9.7MPa during the midstance phase of running. Increasing step rate by 10% significantly reduced mean contact pressures by 10.4% and contact area by 7.4%, but had small effects on lateral patellar translation and tilt. Enhancing vastus medialis strength did not substantially affect pressure magnitudes or lateral patellar translation, but did shift contact pressure medially toward the patellar median ridge. Thus, the model suggests that step rate tends to primarily modulate the magnitude of contact pressure and contact area, while vastus medialis strengthening has the potential to alter mediolateral pressure locations. These results are relevant to consider in the design of interventions used to prevent or treat patellofemoral pain in runners.

Effects of foot orthoses on Achilles tendon load in recreational runners

BackgroundAchilles tendon pathology is a frequently occurring musculoskeletal disorder in runners. Foot orthoses have been shown to reduce the symptoms of pain in runners but their mechanical effects are still not well understood. MethodsThis study aimed to examine differences in Achilles tendon load when running with and without orthotic intervention. Twelve male runners ran at 4.0m·s−1. Ankle joint moments and Achilles tendon forces were compared when running with and without orthotics. FindingsThe results indicate that running with foot orthotics was associated with significant reductions in Achilles tendon load compared to without orthotics. InterpretationIn addition to providing insight into the mechanical effects of orthotics in runners, the current investigation suggests that via reductions in Achilles tendon load, foot orthoses may serve to reduce the incidence of chronic Achilles tendon pathologies in runners.

Explicit finite element modelling of heel pad mechanics in running: inclusion of body dynamics and application of physiological impact loads

Many heel pathologies including plantar heel pain may result from micro tears/trauma in the subcutaneous tissues, in which internal tissue deformation/stresses within the heel pad play an important role. Previously, many finite element models have been proposed to evaluate stresses inside the heel pad, but the majority of these models only focus on static loading boundary conditions. This study explored a dynamics modelling approach to the heel pad subjected to realistic impact loads during running. In this model, the inertial property and action of the body are described by a lumped parameter model, while the heel/shoe interactions are modelled using a viscoelastic heel pad model with contact properties. The impact force pattern, dynamic heel pad deformation and stress states predicted by the model were compared with published experimental data. Further parametrical studies revealed the model responses, in terms of internal stresses in the skin and fatty tissue, change nonlinearly when body dynamics changes. A reduction in foot's touchdown velocity resulted in a less severe impact landing and stress relief inside the heel pad, for example peak von-Mises stress in fatty tissue, was reduced by 11.3%. Applications of the model may be extendable to perform iterative analyses to further understand the complex relationships between body dynamics and stress distributions in the soft tissue of heel pad during running. This may open new opportunities to study the mechanical aetiology of plantar heel pain in runners.

The runner's kidney: A case report

Kidney somatic dysfunction could be easily missed when treating a runner as pain in runners is usually biomechanical. In this case report, a 51 year old woman with pain in her gluteus while running is presented. After treatment with physical therapy and structural osteopathic manipulation, there was no improvement. Once the key lesion (a second degree kidney ptosis) was found and treated, the patient could resume her training without any pain.

Prospective analysis of intrinsic and extrinsic risk factors on the development of Achilles tendon pain in runners

There are currently no generally accepted, consistent results that clearly characterize factors causing Achilles tendon pain (AT) in runners. Therefore, we carried out a prospective study to evaluate the multifactorial influence of clinical, biomechanical (isometric strength measurements and three‐dimensional kinematics) and training‐related risk factors on the development of AT. Two hundred sixty‐nine uninjured runners were recruited and underwent an initial examination. One hundred forty‐two subjects completed their participation by submitting training information on a weekly basis over a maximal period of 1 year. Forty‐five subjects developed an overuse injury, with 10 runners suffering from AT. In an uninjured state, AT runners already demonstrated decreased knee flexor strength and abnormal lower leg kinematics (sagittal knee and ankle joint) compared with a matched control group. A relationship between years of running experience or previous overuse injuries and the development of new symptoms could not be established. The interrelationship of biomechanical and training‐specific variables on the generation of AT is evident. A combination of alterations in lower leg kinematics and higher impacts caused by fast training sessions might lead to excessive stress on the Achilles tendon during weight bearing and thus to AT in recreational runners.

Prospective Evidence for a Hip Etiology in Patellofemoral Pain

Patellofemoral pain (PFP) is the leading cause of knee pain in runners. Proximal and distal running mechanics have been linked to the development of PFP. However, the lack of prospective studies limits establishing a causal relationship of these mechanics to PFP. The purpose of this study was to prospectively compare running mechanics in a group of female runners who went on to develop PFP compared with healthy controls. It was hypothesized that runners who go on to develop PFP would exhibit greater hip adduction, hip internal rotation, and greater rear foot eversion. Four hundred healthy female runners underwent an instrumented gait analysis and were then tracked for any injuries that they may have developed over a 2-yr period. Fifteen cases of PFP developed, which were confirmed by a medical professional. Their initial running mechanics were compared to an equal number of runners who remained uninjured. We found that female runners who developed PFP exhibited significantly greater hip adduction (P = 0.007). No statistically significant differences were found for the hip internal rotation angle (P = 0.47) or rear foot eversion (P = 0.1). The finding of greater hip adduction in female runners who develop PFP is in agreement with previous cross-sectional studies. These results suggest that runners who develop PFP use a different proximal neuromuscular control strategy than those who remain healthy. Injury prevention and treatment strategies should consider addressing these altered hip mechanics.

February 2012 Letters to the Editor-in-Chief

February 2012 Letters to the Editor-in-Chief

Plantar Fasciitis

This issue provides a clinical overview of plantar fasciitis focusing on prevention, diagnosis, treatment, practice improvement, and patient information. Readers can complete the accompanying CME quiz for 1.5 credits. Only ACP members and individual subscribers can access the electronic features of In the Clinic. Non-subscribers who wish to access this issue of In the Clinic can elect "Pay for View." Subscribers can receive 1.5 category 1 CME credits by completing the CME quiz that accompanies this issue of In the Clinic. The content of In the Clinic is drawn from the clinical information and education resources of the American College of Physicians (ACP), including PIER (Physicians' Information and Education Resource) and MKSAP (Medical Knowledge and Self Assessment Program). Annals of Internal Medicine editors develop In the Clinic from these primary sources in collaboration with the ACP's Medical Education and Publishing division and with assistance of science writers and physician writers. Editorial consultants from PIER and MKSAP provide expert review of the content. Readers who are interested in these primary resources for more detail can consult www.acponline.org, http://pier.acponline.org, and other resources referenced within each issue of In the Clinic.

Landing Pattern Modification to Improve Patellofemoral Pain in Runners: A Case Series

Case series. Patellofemoral pain is a common overuse injury in runners. Recent findings suggest that patellofemoral pain is related to high-impact loading associated with a rearfoot strike pattern. This case series describes the potential training effects of a landing pattern modification program to manage patellofemoral pain in runners. Three female runners with unilateral patellofemoral pain who initially presented with a rearfoot strike pattern underwent 8 sessions of landing pattern modification program using real-time audio feedback from a force sensor placed within the shoe. Ground reaction forces during running were assessed with an instrumented treadmill. Patellofemoral pain symptoms were assessed using 2 validated questionnaires. Finally, running performance was measured by self-reported best time to complete a 10-km run in the previous month. The runners were assessed before, immediately after, and 3 months following training. The landing pattern of runners was successfully changed from a rearfoot to a nonrearfoot strike pattern after training. This new pattern was maintained 3 months after the program. The vertical impact peak and rates of loading were shown to be reduced. Likewise, the symptoms related to patellofemoral pain and associated functional limitations were improved. However, only 1 of the participants reported improved running performance after the training. This case series provided preliminary data to support further investigation of interventions leading to landing pattern modification in runners with patellofemoral pain. Therapy, level 4.

Application of wedged foot orthosis effectively reduces pain in runners with pronated foot: a randomized clinical study

Objective: To examine the effects of foot orthosis intervention during a 60-minute running test in pronated-foot runners with overuse knee or foot pain during running. Design: A randomized, controlled design. Setting: Sports gym. Participants: Twenty-four runners with pronated foot who experienced pain over anterior knee or foot region during running were recruited and randomized into the treatment, or the control, group. Interventions: A soft insole with a semi-rigid rearfoot medial wedge was given to the treatment group, and a soft insole without corrective posting was applied to the control group. Outcome measures: The immediate and short-term effects of orthosis application on incidence of pain, pain intensity and onset time were evaluated using the 60-minutes treadmill test. Results: Immediately after wearing the foot orthosis, pain incidence reduced in the treatment group but not in the control group (P = 0.04). After two weeks, seven (58%) subjects in the treatment group and one (8%) in the control group were free of pain during the test (P = 0.01). The pain intensity score decreased significantly after orthosis application, from 35.5 to 17.2 (immediate effect, P = 0.014), then to 12.3 (short-term effect, P < 0.001). Conclusion: The rearfoot medially-wedged insole was a useful intervention for preventing or reducing painful knee or foot symptoms during running in runners with pronated foot.