diagnosis and treatment of musculoskeletal running injuries

Diagnosis and Treatment of Musculoskeletal Running Injuries

By John G. Paty, Jr

INDEX WORDS: Running; trauma; injury; pain; fitness; stress fracture.

W ITH THE ADVENT of running for exercise during the last two decades, over 30

million people in the United States are running; 10 million run regularly.‘-3 San Francisco’s Bay to Breakers 7.6 mile race has grown from a field of 15 runners in 1963 to 75,000 in 1984.4 16,000 runners participated in the 1985 New York Marathon; the oldest male finisher was aged 85 and the oldest female, 75. Commensurate with this exponential growth in running, physicians have had to become proficient in the diagnosis and treatment of musculoskeletal injuries incurred by runners. Clearly the “fitness boom” is continuing, and in many instances, selfinduced injury is the byproduct. Only humans and two others of the animal kingdom whose activities are related to theirs (the race horse and the greyhound) experience stress fractures.’ Running injuries affect at least 60% of runners; moreover, many use injury as their endpoint in mileage and intensity of training. In a group of 180 runners, James et al noted that 65% of the injuries occurred in distance runners, 9% in sprinters and middle distance runners, 24% in joggers (low-mileage runners), and 2% in hurdl- ers and decathletes.6

ETIOLOGY

Most running injuries are not the result of biomechanical abnormality but of training error-either too rapid increase in mileage or intensity (overuse) or failure to attend to strength and flexibility. ‘-’ Less common training errors are wearing inadequate or worn out shoes or running on cambered or uneven surfaces. Although hard surfaces (asphalt, concrete) may

From the Arthritis Associates, Chattanooga, Tennessee. John G. Paty, Jr, MD: Clinical Associate Professor of

Medicine, University of Tennessee College of Medicine, Chattanooga.

Address reprint requests to John G. Paty, Jr. MD, Arthri- tis Associates, 979 E Third St, Suite 404. Chattanooga, TN 37403.

o 1988 by Grune & Stratton. Inc. 0049-0172/88/1801-0005%5.0000/0

be a factor in running injuries6 they are a fact of life for most runners and, except for posterior tibia1 syndrome, I do not attribute running injuries to hard surfaces but rather to mileage viola- tions (vide infra). Examples of surface errors might be running in the same direction on a banked (cambered) track, road, or beach, or running in soft sand or (uneven) dirt. Although most runners may have one or more biomechanical abnormalities, injury resulting from these anatomical variations alone account for ~20% of the tota1.‘*7’8

Overuse includes continuous high mileage, failure to follow hard training days with one or more easy days, rapid increase in mileage, inter- val training, a single severe session or competitive session, running on hills, and returning to previous mileage after a layoff.4*6’9*‘o In a random sampling of entrants in a 10 km race responding to a questionnaire in which injury was defined as that associated with a reduction of weekly mileage in the previous 2 years, 46.6% had been injured. Mileage per week, days run per week, number of races run in the previous year, and training pace were significantly associated with injury. Injury was associated with running >30 miles/week, >5 days/week, and faster than 8 minutes/mile average training pace.3 In the studies noted above, average mileage for the injured runner varied between 19 and 49 miles/week. To my knowledge, the specific mileage limitations above which overuse injuries would occur and below which the likelihood of injury would be small have not been published or prospectively evaluated.

In one survey in a rheumatology clinical practice involving 80 runners aged 14 to 65 years with 27 miles average weekly mileage, the percentage of those injured as a result of training error was 73%.’ In a retrospective review of 180 runners with 232 conditions, James et al reported a 60% frequency of overuse.6 In another retrospective survey, Clements et al reported an 8 1% incidence of training error in the etiology of 1,192 injuries in a group of 1,650 runners aged 9 to 63 years with an average weekly mileage of 27 miles for men and 19 miles for women.’ However, these retrospective studies cannot address how many

48 Seminars in Arrhriris and Rheumatism, Vol 18. No 1 (August). 1988: pp 48-60

MUSCULOSKELETAL RUNNING INJURIES 49

Table 1. Definition of Overuse

Novice

Experienced

>6- 12 miles/week

> lO%/month increase in mileage

Single run ~3 times average daily

mileage

Speed training before 25 miles/week

for 3 months

Frequent hill or speed work (hard/

easy)

Continuous high mileage >25 miles/

week

Return to orevious mileage after layoff

runners commit training errors but escape injury. In my own practice, the majority of injured runners have violated one or more of the guidelines in Table 1; I have found these guidelines useful in defining overuse and in making mileage recommendations to novice and experienced runners. Knowledge of the patient’s training tech- nique is essential, for as the physician evaluates the runner, a review of his or her running history will often indicate not only the diagnosis but also the etiology of the running injury.

RUNNING HISTORY

The initial questions the physician should ask the runner concern (1) duration of running activity, (2) weekly mileage and recent changes in mileage and intensity, (3) running surface, (4) stretching and strengthening activity, (5) previous musculoskeletal complaints, and (6) other aerobic activity. Previous injury or musculoskeletal complaints should be inquired about, as injuries often occur in previously injured extremities. I have also attended several athletes whose previous complaints were a clue to spondyloarthro- apathy or osteoarthritis. A history of other aerobic activity, such as aerobic dance classes may be significant, as this activity adds to the musculoskeletal load.

The next group of questions is directed at the characteristics of the patient’s pain. The physician should inquire about (1) the location of pain, (2) the duration of pain, (3) whether the pain occurred at the beginning, during, at the end, or after running, (4) the effect of hills or speed, (5) the effects of squats or stairs on knee injuries, and (6) morning stiffness or gelling. Injuries with symptoms occurring only at the beginning of the run, throughout it, or near the end would be heel spur syndrome, stress fracture, and iliotibial

band syndrome, respectively. Examples of symptoms worsening with fast running or running up and down hills might be adductor/hamstring tendinitis or disorders of the knee extensor mechanism. Pain with squatting or climbing stairs, with knee complaints, or morning stiffness and gelling with heel pain are other clues important to the diagnosis.

PHYSICAL EXAMINATION

The physical examination is made up of gen- eral physical and biomechanical examina- tions.2*6’1’ The biomechanical examination should include the following measurements: (1) Leg length discrepancy, which may account for hip pain on the long leg side. This should be measured from the anterior iliac crest to the medial malleolus. A difference of 1 cm or less is within normal limits. (2) Range of motion of the hips- ideally, motion should be 90“ or more with external rotation equal to or greater than internal rotation. Excessive internal rotation in femoral antiversion may contribute to knee pain. (3) Dorsiflexion of the ankle-measured with the patient supine and the knee extended, loo is minimal normal active dorsiflexion at the ankle. Limited dorsiflexion may cause pronation and contributes to Achilles, calf muscle, and other leg, ankle, and foot injuries. (4) Subtalar varus-measured with the patient prone and the subtalar joint in neutral position, this is the angle made by a line bisecting the calf and the posterior calcaneus. Normal is O” to 4O. Excessive rearfoot varus is a cause of overpronation. (5) Subtalar motion-normal is approximately 20° of inversion and loo of eversion. Patients with previous ankle injuries may have limited subtalar motion or excessive inversion. (6) Abnormal forefoot alignment in a plane intersecting a verti- cal line through the posterior calcaneus is almost always supination (forefoot varus) and may be another cause of pronation. (7) The Q angle- measured with the patient standing, the angle is made by a line drawn from the anterior iliac crest to midpatella and a line from midpatella to the tibia1 tubercle. A Q angle ~20~ may contribute to patellofemoral arthralgia. (8) Observation of the patient’s walk-the physician may observe pes planus, high arched foot, rearfoot varus (supination), rearfoot valgus (pronation), midfoot pronation, and tibia varum, which causes prona-

50 JOHN G. PATY

tion. In patients with hip or back pain, the Trendelenberg test is performed by having the patient alternate standing first on one foot and then the other while the physician observes sym- metry and position of the buttock (observation for weakness in the hip abductors). Observation for pelvic tilt, scoliosis, and lumbar motion should also be performed. (9) Examination of the patient’s shoes is one of the most important aspects of the running examination. As the percent glycohemoglobin shows glucose intolerance, so the shoe examination may give clear evidence of prolonged or excessive pronation or supination. Tibia1 rotation that occurs with either pronation or supination may contribute to medial or lateral knee pain, respectively.6 Running consists of a swing phase and a stance phase. At initial heel strike of the stance phase, the foot is in supination (contact period) and moves rapidly to pronation to absorb shock (the midtarsal joint “unlocks”). The midstance period continues through 70% of the stance phase, with maximum pronation occurring when the runner’s center of gravity passes over the weight-bearing foot. Fol- lowing maximum pronation, the subtalar joint gradually supinates so that the foot is in supination at the end of midstance. During the last one third of the stance phase, the foot is in supination and the midtarsal joint is stabilized, creating a rigid lever for pushoff. In patients with limited dorsiflexion, subtalar varus, forefoot varus, and tibia varum, pronation will be excessive and supination during the late midstance will be delayed because the foot has to “roll over” further to make ground contact. Excessive or pro-

Table 2. Biomechanical Examination

Examination NWllWl

Leg length

Range of motion, hip

Dorsiflexion, ankle

Subtalar varus

Subtalar motion

Forefoot alignment

Cl angle

Walk observation

Examination of injured

area

Difference i 1 cm

290” external 2 internal

2100

00 to 4”

Total, 30”: 2: 1 inversion/eversion

perpendicular to calcaneus

520”

Tibia varum, high arches, pes

planus, rearfoot varus or valgus.

midfoot pronation,

Trendelenberg test

Varus or valgus tilt, outer sole

wear

Swelling, tenderness, range of motion

longed pronation is associated with increased stress on the supporting structures and the intrin- sic and extrinsic muscles of the foot.6V’2,‘3 (10) Finally, the area of the injury is examined for swelling, tenderness, and range of motion. (Table 2) Ancillary measures such as x-rays are often not necessary. However, x-rays may be helpful in excluding stress fracture or bony abnormalities such as osteochondritis dessicans. When the diagnosis is in doubt, or if there is an urgency to get the runner back on the road, a bone scan may be useful. When the x-ray is negative, a bone scan will usually differentiate soft tissue injury from bone stress or stress fracture.

MUSCULOSKELETAL INJURIES

Clinical Pathology

With few exceptions, musculoskeletal injuries are the result of microtrauma to bone, ligaments, or muscle-tendon units. These injuries are more likely to occur in tendon synovial sheaths or bursae than in tendons, and at tendon origins and insertions or musculotendinous interfaces rather than in muscle belly. They may be pelvic, hip, and thigh, knee, leg, or foot and ankle injuries. Knee injuries predominate, accounting for more than one third of running injuries. Pelvic, hip, and thigh injuries account for approximately lo%, and the remaining SO% of injuries are divided between leg and foot and ankle. In our 80 patients, knee injuries accounted for 35% and pelvic, hip, and thigh injuries for 12%.’ In the 1,650 patients reported by Clement et al, injuries were 42% knee, 12% pelvic, hip, and thigh, 28% leg, and 18% foot and ankle.* However, since only 14% to 70% of injured runners seek “profes- sional medical care,“3 surveys may not reflect the actual incidence and may select more recalcitrant injuries. In 120 runners, men experienced significantly more knee injuries and women experienced significantly more pelvic, hip, and thigh and leg injuries (Paty JG and Swafford DM, unpublished data). Differences in musculoskeletal injuries for men and women were not noted in the larger study by Clement et a1.8 In a prospective evaluation of injuries in a sports medicine clinic, Micheli noted an increased incidence of patellofemoral arthralgia in women athletes.14 Stress fractures are more common in adolescent girls, in spite of lower mileage, than in boys. This disparity suggests less physical activ-

MUSCULOSKELETAL RUNNING INJURIES

ity before running or less bone and muscle mass after puberty in adolescent girls.’ There is not uniform agreement on stress fracture differences in adult runners.‘e’6 However, women may be more susceptible than men to injuries as a result of a relatively low level of athletic training and physical activity before running.14

Pelvic, Hip, and Thigh Injuries

Common to all stress fractures is a history of overuse. The fracture can always be related to a single or series of excessive workouts over a short period of time. Frequently, the stage may be set by persistent high mileage (>25 miles/week). Pain occurs with walking or as soon as running begins and increases with continuation of running. Tenderness is present over the area involved. Limited or painful range of motion of the hip will be present if the femoral neck is involved. Standing on one leg on the involved side will produce pain.” The index of suspicion must be high because initial x-ray is often unremarkable. (Fig 1). Avulsion fractures of the pelvis may be encountered in adolescent athletes. Any of the

51

five pelvic epiphyses may be involved as a result of sudden muscle tension across an open epiphysis.” In runners, the iliac crest epiphysis and anterior superior iliac spine are injured most often. This history is similar to stress fracture of the bone. In iliac crest epiphyseal injury, pain is elicited by leaning away from the injured area because of external oblique pull, and point tenderness is present over the iliac crest. X-rays will reveal a disruption in the continuity of the iliac crest epiphysis on the involved side when compared with the uninvolved side. Inflammatory or traumatic sacroiliitis may cause buttock or hip pain, sciatica, or morning stiffness. Symptoms may occur during or after running.

Gluteus medius strain and tendinitis or trochanteric bursitis account for over one half of the hip injuries. The patient complains of pain with walking or running, sitting or lying on the involved side, or rising from a sitting position. There may be a history of running on a banked surface or of overuse. On physical examination, leg length discrepancy may be present with normal hip motion and point tenderness. The Tren-

Fig 1. lschial ramus stress fracture in 60-year-old female runner. 7 months after first visit for left hip pain following increase in weekly mileage from 30 to 36 miles.

52 JOHN G. PATY

delenberg test may be positive due to pain or weakness of the hip abductors on the symptomatic side.14 Symptoms tend to occur on the long leg side but may occur in either hip,19 (also Paty JG, Swafford DM, unpublished data) when running on a banked surface. Adductor and hamstring tendinitis may cause groin and posterior thigh pain, and often occur together. Adductor tendinitis may also be accompanied by or even simulated by osteitis pubis.” Symptoms occur with and often follow highspeed or hill runs or runs on cambered surfaces. Frequently, little attention has been paid to stretching in these disorders. Pain is elicited with resisted adduction in adductor tendinitis, and the hamstring or “hurdle stretch” in hamstring tendinitis. Tender- ness is present over the medial proximal groin near the symphysis pubis or ischial tuberosity. Two other less common disorders are “low back” pain and piriformis syndrome. Both occur in high-mileage runners and should be distin- guished from lumbar disk disease.16 Low back symptoms include dull or sharp pain with running and often occur as a result of inflexibility of the spine extensors and inadequate abdominal muscle strengthening.” Piriformis strain or compression of the sciatic nerve causes buttock pain or sciatica. Symptoms may be improved with removal of a wallet from the runner’s back pocket” (Table 3).

Knee Injuries

The iliotibial band syndrome, patellofemoral stress syndrome or patellofemoral arthralgia,quadriceps tendinitis, and patellar tendinitis account for more than three fourths of running knee injuries. In the iliotibial band syndrome, history indicates high mileage, often with a recent increase in mileage or intensity, hill running, running on a surface that puts varus stress on the knee, or excessive varus shoe wear with consequent lateral stress on the knee. The pain arises from a bursitis from friction as the band moves back and forth over the lateral femoral epicondyle. Twenty percent of patients complain of bilateral pain.*’ Typically, pain occurs only with running. The runner may be able to run painlessly for several miles, but as the run pro- gresses the pain increases, eventually requiring him or her to stop. Pain may occur after a constant distance and continued attempts at run-

Table 3. Common Runnina Injuries

Pelvic, hip, and thigh Stress fracture-pubic rami,

ischium, femoral neck or shaft

Epiphyseal stress fracture

Gluteus medius strain/tendinitis

Trochanteric bursitis

Traumatic or inflammatory sacro-

iliitis

Adductor/hamstring tendinitis

Knee lliotibial band syndrome

Patellofemoral arthralgia

Patellar/quadriceps tendinitis

Anserine bursitis

Medial retinaculitis

Medial plica syndrome

Popliteal tenosynovitis

Leg Posterior tibia1 syndrome

Tibia1 stress syndrome/stress frac-

ture-tibia or fibula

Chronic compartment syndrome

Calf muscle tear

Foot and ankle Plantar fesciitis/heel spur syn-

drome

Achilles peritendinitis/tendinitis

Peroneal tenosynovitis/tendinitis

Dorsal/anterior tibia1 tenosynovitis

Ankle sprain

Metatarsalgia

Metatarsal stress fracture

ning only recreate the pain at the same or a lesser mile point. Walking and jogging in place are painless since the band remains anterior to the epicondyle. Although symptoms may occur with stair climbing, squatting and rising from a sitting position are usually painless because the band crosses two joints and knee effects may depend on hip extension.*l Positive physical findings are confined to tenderness and, on occasion, swelling over the lateral femoral epicondyle. Iliotibial band syndrome may disappear when the runner discards shoes that have varus tilt or avoids running on a cambered surface. The physician may have difficulty in differentiating iliotibial band syndrome from popliteal tenosynovitis. However, characteristic features of the latter are pain when running downhill (secondary to increased forward tibia1 force), pain with flexion of the affected knee to 90° while placing the lateral malleolus on the opposite leg, and tenderness anterior, posterior, and superior to the lateral collateral ligament.1’*‘9*22

Precipitating events may not be apparent in


patellofemoral arthralgia, and although it is common in teenagers, it also may be presenting manifestation of degenerative joint disease in older patients. Unlike iliotibial band syndrome, pain may be worse after running. As with all the disorders of the extensor mechanism of the knee, the pain is most noticeable when the patient squats, gets out of a chair, or climbs or descends stairs. Symptoms may occur in low-mileage runners without training errors. The etiology of symptoms may not be readily apparent, but contributory factors may be abnormal patellar pressures secondary to a wide Q angle or excessive pronation. In teenagers increased patellar pressures may occur as a result of quadriceps inflexibility secondary to overly rapid bone growth. 23 Lateral excursion secondary to a lax medial retinaculum, weak quadriceps, tight lateral stabilizing structures, or flattened lateral femoral condyle may also contribute to patellofemoral arthralgia. The pain is believed to originate from subchondral bone nerve endings, but it may be secondary to patellar fat pad impinge- ment, retinacular strain, or synovial plica. Overt pathology of the patella is usually not present, and the term “chondromalacia patellae” should be reserved for patellar cartilage degeneration.24 Quadriceps atrophy, tenderness under the medial border of the patella, and crepitance and pain elicited by gripping the patella as the patient contracts the quadriceps (apprehension/patellar inhibition sign) are characteristic features of patellofemoral arthralgia. Occasionally an effu- sion secondary to reactive synovitis or osteoarthritis may be present.

With regard to knee effusions, in the prelimi- nary phase of a prospective study of osteoarthritis in the knees, hips, and ankles in asymptomatic runners with a weekly mileage of 30 miles or more, 25% had knee effusions.25 Although this study showed statistically significant association of effusions with x-ray findings consistent with mild osteoarthritis, evaluation of runners and their nonrunner controls over years or even decades may be required to establish their rele- vance to symptomatic osteoarthritis. Other studies have not shown an association between distance running and osteoarthritis.26s27 Panush et al compared the prevalence of osteoarthritis in 17 male runners (with an average age of 56 years who had been running 28 miles/week for 12

years) with 18 nonrunning controls. As the inves- tigators point out, although there were no differences in the incidence of osteoarthritis in the two groups, persons who had begun to run but had discontinued running would not have been included.26 Using a questionnaire, Sohn and Micheli noted a similar low incidence of knee and hip pain in former collegiate cross country runners and nonrunners.

For the patient with quadriceps or patellar tendinitis, the culprit may be repetitive squats, isotonic knee extensions with weights, or overuse (particularly hill running). Symptoms occur with running and, as with patellofemoral arthralgia, on arising from a sitting position, when squatting, or when going up or down stairs. Tenderness is present over the superior pole of the patella in quadriceps tendinitis and near the inferior pole of the patella, at the attachment of the patellar tendon, in patellar tendinitis (jumper’s knee).

Fig 2. Proximal tibia1 stress fracture simulating pes anserine bursitis in a 39year-old man who had run 50 miles/week for 4 years.

54 JOHN G. PATY

Typically, both of these entities are overuse syndromes requiring prolonged periods of absti- nence from running for resolution.

Three less common causes of medial knee pain are anserine bursitis, medial retinaculitis, and medial plica syndrome. Features of pes anserine bursitis or tendinitis are high mileage, medial knee pain, and tenderness over the proximal medial tibia. Since the pes bursa separates the three tendons (gracilis, sartorius, and semitendi- nosus) from the medial collateral ligament, tenderness may be present over the medial collateral ligament with the knee in extension.“*** X-rays should be taken to exclude proximal tibia1 stress fracture. (Fig 2) Medial retinaculitis may be differentiated from patellofemoral arthralgia in that it tends to occur in high-mileage runners (who often have recent excessive mileage) and tenderness is present over the anterior medial edge of the patella.lg Synovial plica, particularly the medial patellar plica (synovial shelf), may become inflamed (synovitis) as it slides over the femoral condyle as a result of trauma or, in the case of the runner, as a result of overuse. Symp- toms may simulate patellofemoral arthralgia and may include knee pain with running, a sensation of instability, and swelling. Tenderness may be present over the femoral condyle or medial or lateral to the superior pole of the patella. Often a tender, bandlike structure can be palpated paral- lel to the medial border of the patella. A palpable or audible snap may be present during flexion and extension of the knee.*’

Leg Injuries

Posterior tibia1 syndrome is relatively uncommon in well conditioned runners and is associated with excessive mileage, fast running, running on hard surfaces, and pronation. Pain occurs along the anteromedial border on the lower half of the tibia and is secondary to a “periosteal reaction or fatigue microtrauma to the musculotendinous insertion into bone.“5 The inflammatory reaction may involve tendon sheath (tenosynovitis), tendon, muscle, or periosteum. Tenderness is present over the posteromedial border of the distal half of the tibia, occasionally with swelling, and it may often be bilateral. The patient’s running shoes may reveal pronation. Excessive pronation increases internal tibia1 rotation and strain to the posterior tibia1 tendon.‘* Diffuse tenderness may

differentiate posterior tibia1 syndrome from tibia1 stress syndrome or stress fracture. How- ever, with posterior tibia1 syndrome the patient may continue to run, with pain actually worse at the beginning of the run but improving as the run continues. Pain usually recurs after running and may be associated with morning stiffness and gelling. This “warming up” phenomenon is characteristic of initial onset tendon syndromes of the leg and foot and ankle (and of heel spur syndrome). However, if symptoms persist pain may worsen with running. Although bone scans may be useful in differentiating posterior tibia1 syndrome from stress fracture, occasionally they may be positive in the former.*’ (Fig 3)

The tibia1 stress syndrome and stress fractures of the tibia and fibula (less common) are characterized by overuse, pain with running, and point tenderness. Frequently a nodule may be palpated over the posteromedial, proximal, or distal tibia or fibula. Bone stress is a continuum from resorption to new bone formation. Tibia1 stress syndrome is an adaptation to stress through internal remodeling so that complete fracture does not result. Fracture may appear if excessive stress continues in a tibia weakened by osteoclastic resorption.‘2.30 Positive bone scan (Fig 4) and eventual periosteal new bone formation (callus) may be seen in both of these conditions, but the term “stress fracture” should be used only when there is cortical infraction or cancellous sclerosis.3’

The chronic compartment syndrome is a compression syndrome in the anterior compartment (anterior tibialis, extensor hallucis longus, and extensor digitorum) or media13* (deep posterior) compartment (flexor hallucis longus, flexor digitorum longus and tibialis posterior). During either walking or running, pressure in the osteo- fascial space between the tibia and fibula increases, with compromise of the arteriolar cir- culation to the nerves and muscles in the compartment. The etiology is unknown, but increase in muscle volume with exercise, as a result of interstitial fluid accumulation and mechanical factors during muscle contraction, produces an increase in intramuscular pressure that is depen- dent on the size and compliance of the osteofas- cial space.33 Symptoms suggest intermittent claudication34 and may occasionally occur in the lateral compartment (peroneus longus and bre-


Fig 3. Bone scan in 38-year-old male sporadic runner showing bilateral midtibiel

linear increased uptake seen in posterior tibia1 syndrome.

vis)33s35 and superficial posterior (gastrocnemius and soleus). Anterior tibial, medial tibial, or calf pain that disappears after a few minutes rest is typical. However, symptoms may occasionally persist for hours or days. Physical findings may be unremarkable or may reveal tenderness over the symptomatic area. Pulses are normal unless the patient has peripheral vascular disease. Rare- ly, a chronic compartment syndrome will evolve into an acute syndrome. Diagnosis of chronic compartment syndrome can be made reliably by measurement of compartment pressures with a catheter or needle before and after exercise. Intramuscular pressure will be elevated at rest and after exercise. 33 Symptoms will usually be relieved by fasciotomy.32”5

Calf muscle or musculotendinious interface

strains or tears of the gastrocnemius or the soleus muscle are associated with overuse and often with a history of inadequate stretching. Injury is acute, occurring well into the run. The patient describes a sudden snapping or tearing in the calf as if he has been “shot.” Continued running or even walking is painful, causing the patient to limp. Tenderness, swelling and hematoma will frequently be present over the posterior midcalf, and if the history is not obtained, this may be confused with thrombophlebitis.

Foot and Ankle Injuries

The pain in heel spur syndrome is secondary to inflammation of the origin of the plantar fascia at the calcaneal tuberosity, a subcalcaneal bursitis, or, infrequently, entrapment of the medial

56 JOHN G. PA-W

heel branch of the calcaneal nerve. The heel spur, which may be present on x-ray, is a response to plantar fascia tension stress and not the cause of heel pain. I6 Patients camp lain of heel and arch pain. Pain occurs with weight bearing but improves after a few steps or several minutes of walking or running, only to recur after inactivity. Tenderness is present over the inferior anteromedial calcaneus and less often over the arch. In runners, the heel spur syndrome is not neces- sarily associated with overuse. It is usually chronic and may persist for months or years without treatment, even with cessation of running. A high percentage of patients with heel spur syndrome have high-arched feet, and most benefit from orthoses and are able to continue their running.

Posterior foot and ankle pain may originate from microtrauma and secondary inflammation of the Achilles peritendon or Achilles tendon or

Fig 4. Bone scan in a 32-year-old female runner with left leg pain 2% weeks after first marathon. X-ray showed tibia1 callus without subsequent development of cortical infraction or cancellous sclerosis (tibia1 stress syndrome).

the retrocalcaneal bursa. Achilles peritendinitis may be associated with overuse (particularly speed work or hill running), varus alignment of the foot, or inadequate stretching. Retrocalca- neal bursitis occurs as a separate entity and causes pain and tenderness over the posterior calcaneus. The Achilles tendon has no synovial sheath but is surrounded by the more vascular filmlike peritendon.‘0s37 Injury most commonly involves the peritendon. If the peritendinitis per- sists, cystic mutinous degeneration of the tendon may toll the end of running for the athlete. Clinical signs are eventual pain with running, morning stiffness, tenderness, swelling, and occasionally crepitus. If the tendon is affected, nod- ules may be palpated. Tight calf muscles and pronation, as a result of subtalar or forefoot varus, are common. Functional pronation may produce a “whipping” action on the Achilles tendon.”


Peroneal tenosynovitis involving the tendon sheath of the peroneus longus and brevis is characterized by lateral lower leg or ankle pain, overuse, poor ankle flexibility, varus shoe wear, or history of ankle sprain. As in other tendon syndromes, symptoms initially may improve with running, but eventually worsen during running. Tenderness and occasionally swelling are present over the distal fibula, posterior and inferior to the lateral malleolus, over the fifth metatarsal sty- loid at the insertion of the peroneus brevis, or over the cuboid bone extending on to the sole of the foot.36 Pain may be elicited as the physician resists the patient’s active eversion of the foot.

Dorsal tenosynovitis anterior to the ankle or dorsum of the foot can usually be attributed to a single long run or too tight shoelaces. Metatar- salgia due to repetitive impact loading (often occurring in the runner aged over 30 years),38 exacerbated by hard surfaces and inadequately cushioned or poorly fitted shoes, may cause forefoot pain as a result of bursitis and ligamentous strain between the metatarsal heads, callosities under the metatarsophalangeal joints, Morton’s neuroma, or degenerative arthritis of the first metatarsophalangeal joint.39 Stress fractures of the foot occur most often in the diaphysis of the second and third metatarsal bones.29 In my experience, they are relatively uncommon in high- mileage runners and frequently occur as an overuse syndrome in female novice runners, often with as little as a two-mile run. Pain with walking and running is present, accompanied by swelling over the dorsum of the foot and localized tenderness and nodularity over the involved metatarsal bone. Ankle sprains (grade I or II) in runners are usually inversion injuries and frequently the result of the runner stepping on an object or in a hole while running in the dark or on uneven terrain. Running shoes are designed for unidirec- tional motion and provide little support for lateral movement and, consequently, may make ankle sprain more likely on uneven terrain or if worn in other sports such as tennis or racquet- ball.@

DISCUSSION AND TREATMENT

One of the gratifying aspects of attending runners is that with only a thorough history and physical examjnation, the physician can usually arrive at the diagnosis and the treatment that, in most cases, will make it possible for the runner to

Table 4. Treatment of Running Injuries

Reduction, and occasionally cessation, of running

until symptoms clear

Substitution with alternate aerobic activity

Stretching/strengthening

Orthoses

RICE (for ankle sprains)

Heel lift (for Achilles/calf muscle injury)

Metatarsal cookies (for metatarsalgial

Shoe change if nail brushing or heel counter

varus or valgus or outer sole wear

Change of surface

Orthopedic referral

Nonsteroidal antiinflammatory drugs

Corticosteroid injection

Abbreviation: RICE, rest, ice, compression, elevation.

return to his or her previous level of activity. The patient must understand the reason for the injury, its cure, and how to prevent further injury. It is no longer appropriate in most cases to tell the patient to stop running. To the runner, a prescription to give up running to avoid injury is as logical as telling a patient with pneumonia to give up breathing to avoid aerosolized bacteria or viruses. Therefore, a reduction in mileage and substitution with alternate aerobic activity (such as biking or swimming) until symptoms have cleared should be recommended. (Table 4) Stress fractures, epiphyseal stress fracture, patellar/quadriceps tendinitis, calf muscle tear, and Achilles peritendinitis require cessation of running until symptoms resolve and tenderness has disappeared. Running in deep water with a life jacket may be used.4’ Once symptoms have resolved, a return to previous running activity may be resumed, using a gradual increase in mileage to preinjury levels over several weeks or months. In those who are required to stop running temporarily, returning to running should be prescribed using a 15 minute slow run (slow enough to talk comfortably-the Bowerman talk test) every other day, with 5-minute increases weekly. When 40 minutes of painless running have been achieved, distance may be increased by the 10% rule. Less than 20% of patients will not be able to return to running activity. Most will be back to running within 3 months.‘s8

Stretching and Strengthening

Crucial to the patient’s rehabilitation and continued successful running is a good stretching and strengthening program, which can often prevent injuries to the muscle-tendon unit.42

58 JOHN G. PATY

Additionally, strengthening exercises may prevent muscle imbalance that contributes to running injuries. The scientific explanation of the physiology of stretching is incomplete. Its bene- fits appear to be maximization of the elastic recoil properties and compliance of muscle- tendon units.43 Passive stretching may cause soft tissue damage and achieves little benefit. Opti- mum flexibility is achieved by proprioceptive neuromuscular facilitation.42*43 In short, the muscle group being stretched is placed in a stretched position and then contracted. A lo-second isometric contraction is followed by 10 seconds of relaxation in a further stretched position while the antagonist of the stretched muscle is contracted. Isometric contraction of the stretched muscle induces relaxation via the Golgi tendon organs (autogenic inhibition), and contraction of its antagonist through reflex inhibition will further increase muscle relaxation and stretch. Each contraction and relaxation should be repeated at least three times.42*43 After a brief “warm-up” of slow running, the runner should perform flexibility exercises of the posterior ankle, leg, hip, and thigh before and after running. Isometric or isotonic strengthening of their antagonists (anterior tibialis, peroneus, quadriceps, and abdominal muscles) and of the hamstrings, along with exercises for quadriceps, low back, and adductor flexibility should be done after running. Injury may occur if stretching is done ballistically (with bouncing) or without adequate warm-up.2*4342 For specific injuries, strengthening and flexibility exercises should be increased. For example, quadriceps strengthening and flexibility exercises should be increased in patellofemoral arthralgia. Patients who have muscle weakness or atrophy or severely limited flexibility should be referred to a physical therapist familiar with sports injuries. Patients who have had ankle sprains should see a therapist for flexibility and strengthening exercises and for instructions in the use of an ankle board.

Orthoses

Orthoses are invaluable in the management of many running injuries. The name is derived from the Greek work “orthos,” denoting straight. These devices are essentially arch supports extending from the posterior calcaneus to just proximal to the first metatarsophalangeal joint,

designed to limit pronation or distribute forces away from the heel.M*4S They are particularly useful in patients with posterior tibia1 syndrome and patellofermoral arthralgia who pronate. They are indispensable in the treatment of heel spur syndrome. Patients with Achilles periten- dinits may also benefit from orthoses.‘0*45 Ini- tially, orthoses should be worn during both running and nonrunning activities. The physician must remember that orthoses may increase varus stress. Therefore, they may aggravate peroneal tenosynovitis or iliotibial band syndrome, particularly in a patient who does not pronate or has an outward (varus) tilt to the heel counter of his shoes. I prefer custom-made subortholene semi- rigid orthoses, which have some flexibility and a long life. Although the duration of wearing orthoses may be temporary unless the injury is secondary to biomechanical abnormality alone, many runners prefer to continue using orthoses indefinitely in their running shoes.”

Other Treatment

Other modalities that may be helpful are rest, ice, compression, and elevation (RICE) in ankle sprains, heel lifts in Achilles tendon or calf muscle injury conditions, metatarsal cookies or orthoses with a metatarsal bar3’ for metatarsalgia, and change in shoe size (particularly if there is evidence of nail bruising). Shoe recommendations should include referral to a knowledgeable proprietor of running shoes. Pronators should not be fitted with “curve lasted” shoes since these will exacerbate pronation. The runner should expect to pay about $40.00 or more for shoes that feature elevated heels, rigid heel counters, mid- sole cushioning, metatarsal flexibility, and a wide toe box.40 Shoe size should allow a thumb- nail width from the big toe to the front sole. Shoes should be discarded if there is excessive varus or valgus heel counter tilt, even if the sole is not worn out. Change in running surface may be indicated in certain conditions, such as running on grass for posterior tibia1 tendon syndrome or avoidance of cambered surfaces in hip pain or iliotibial band syndrome. Patients with suspected plica syndrome, chronic compartment syndrome, distraction stress fracture of the femoral neck,!6 or suspected mutinous degeneration of the Achilles tendon should be referred to an orthopedic surgeon.


Nonsteroidal Antiinflammatory Drugs

Nonsteroidal antiinflammatory drugs are used infrequently. They may be helpful in controlling pain and swelling in the acute phase of injury to a muscle-tendon unit. However, the runner should be cautioned to avoid using medication to “run through” injuries, because further injury may occur. Antiinflammatory drugs are useful in controlling painful flares of back pain in runners with inflammatory diseases such as ankylosing spondylitis. Corticosteroids injections are effec- tive when symptoms persist and are particularly useful in trochanteric bursitis, gluteus medius strain/tendinitis, recalcitrant patellofemoral arthralgia, retrocalcaneal bursitis, and heel spur syndrome, persisting after application of orthoses.

59

SUMMARY

In summary, musculoskeletal injuries occur in at least 60% of runners. Selfinduced training error accounts for the majority of running injuries. A review of the runner’s mileage, training techniques, biomechanical examination, and shoes will provide clues to the accurate diagnosis and treatment. In most cases it is not correct to categorically advise the runner to stop running, since a modification of running techniques will usually get him or her painlessly “back on the road.” The result will be a grateful patient.

ACKNOWLEDGMENT

The author thanks Janice Bundschu for assistance in the preparation of the manuscript.

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diagnosis and treatment of musculoskeletal running injuries

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