the injured runner: an evidence-based approach. part one: running injuries

The Injured Runner:An Evidence-Based Approach

Allan Besselink, PT, Dip. MDT

Director, Smart Sport International

Smart Life InstituteAustin, Texas

Part One: Running Injuries

Allan Besselink, PT, Dip. MDT 2

Background

● Physical therapist (1988)● McKenzie Diploma (1998)● USA Track and Field● Endurance sports coach

(running, triathlon)● Educator (PT; PTA)● Author - “RunSmart: A

Comprehensive Approach To Injury-Free Running” (2008)


Evidence


Evidence-Based Medicine

“The plural of anecdote is not data”(Frank Kotsonis)

“In God we trust – all others bring data” (Nik Bogduk)



“The conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.”

Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: What it is and what it isn't. Br Med J, 1996; 312:71–72.



But, one problem exists -

– Evidence is of no use if it is not integrated and utilized in the assessment and treatment algorithm

– Evidence must also extend to consumer awareness


Belief Systems

The impact of the provider's belief systems may be greater than the evidence

Ross (1994): – “Our beliefs are the truth;– The truth is obvious;– Our beliefs are based on real data;– The data we select are the real data”


Belief Systems


Belief Systems

“The inability to challenge our belief systems in the face of good scientific evidence is the primary limiting factor in the advancement of both health care and coaching, as well as human performance and injury prevention”

(Besselink 2008)


Belief Systems

It is a very uncomfortable struggle to integrate evidence into your thinking – especially if it is contrary to your current beliefs


Thinking

“To arrive at a contradiction is to confess an error in one’s thinking; to maintain a contradiction is to abdicate one’s mind and to evict oneself from the realm of reality”

(Rand)


Evidence ...

… regardless of it's impact on the provider's bottom line or their personal beliefs

It is an issue of cost, of efficacy, and of autonomy.


Lessons Learned: Back Pain

● What assessments?● What treatments? ● Well-established clinical

guidelines

Use the lessons learned from back pain research!


Evidence


A Brief History OfRunning Injuries

Perceived causes:



Perceived causes:– Muscle imbalances– Lack of flexibility– Incorrect footwear– Leg length discrepancy– Foot structure– Too much speed work– Asymmetry and mal-alignment



30+ years of scientific evidence would indicate:

No specific correlation between anatomic mal-alignment or variations in the lower extremity and any specific pathological entities or predisposition to any “overuse syndromes”



● James SL, Bates BT, Osternig LR. Injuries to runners. Am J Sports Med 1978; 6: 40-50.

● Jacobs SJ, Berson BL. Injuries to runners: a study of entrants to a 10,000 meter race. Am J Sports Med 1986; 14: 151-155

● McQuade K. A case-control study of running injuries: comparison of patterns of runners with and without running injuries. JOSPT 1986; 8: 81.

● Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987; 15: 168-171.


“Normal”

“Malalignment is a term that should be reserved for gross abnormalities, two standard deviations outside the norm”

(Reid 1992)


In the meantime ...

What do patients continue to hear from doctors, chiropractors, and physical therapists treating injured runners?

● Muscle imbalances● Lack of flexibility● Incorrect footwear● Leg length discrepancy● Foot structure● Too much speed work● Asymmetry and mal-alignment


Evidence


MRI And Imaging

Perceived value of imaging in the assessment processDoes the cost of imaging outweigh the benefits?Is imaging relevant and pertinent as a first line of assessment?


MRI And Imaging

● Krampla WW, Newrkla SP, Kroener AH, Hruby WF. Changes on magnetic resonance tomography in the knee joints of marathon runners: a 10-year longitudinal study. Skeletal Radiol 2008; 37(7):619-26.

● Stahl R, Luke A, Ma CB, Krug R, Steinbach L, Majumdar S, Link TM. Prevalence of pathologic findings in asymptomatic knees of marathon runners before and after a competition in comparison with physically active subjects-a 3.0 T magnetic resonance imaging study. Skeletal Radiol 2008; 37(7):627-38.


MRI And Imaging

● Schueller-Weidekamm C, Schueller G, Uffmann M, Bader TR. Does marathon running cause acute lesions of the knee? Evaluation with magnetic resonance imaging. Eur Radiol 2006; 16(10): 2179-85.

● Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi M. 1995 Volvo Award in clinical sciences. The diagnostic accuracy of magnetic resonance imaging, work perception, and psychosocial factors in identifying symptomatic disc herniations. Spine 1995; 20(24):2613-25.


MRI And Imaging

● Guten GN, Kohn HS, Zoltan DJ. 'False positive' MRI of the knee: a literature review study. WMJ 2002; 101(1):35-8.

● Sein ML, Walton J, Linklater J, Harris C, Dugal T, Appleyard R, Kirkbride B, Kuah D, Murrell GA. Reliability of MRI assessment of supraspinatus tendinopathy. British Journal of Sports Medicine 2007; 41(8).


MRI And Imaging

● Lessons learned from back pain: 70% of asymptomatics have a positive MRI

● If a patient has a positive MRI, what does it tell us?

● Similar data exists for shoulders and knees● Well-established clinical guidelines would

indicate that this should not be a first line of assessment


In the meantime ...

What will physicians and chiropractors have the patient do as a first line of assessment?

– MRI– Radiographs– CT scans


Evidence


Assessment Techniques

Perceived value in the clinical reasoning process

Three primary approaches:– Palpation-based– Movement-based– Provocation-based


Palpation

● Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson VM, Murphy LS, Reinsch S. Reliability of spinal palpation for diagnosis of back and neck pain: a systematic review of the literature. Spine 2004; 29(19).

● van Trijffel E, Anderegg Q, Bossuyt PM, Lucas C. Inter-examiner reliability of passive assessment of intervertebral motion in the cervical and lumbar spine: a systematic review. Manual therapy 2005; 10(4): 256-269.


Asymmetry

● Badii M, Shin S, Torreggiani WC, Jankovic B, Gustafson P, Munk PL, and Esdaile JM. Pelvic bone asymmetry in 323 study participants receiving abdominal ct scans. Spine 2003; 28(12): 1335-1339.

– Patients without back pain– 82.7% asymmetrical; 5% > 5mm– previous reports of 24 – 91% (in back pain

patients)– Can this be palpated?


Sacroiliac Joint

● Sturesson B, Selvik G, Udén A. Movements of the sacroiliac joints. A roentgen stereophoto-grammetric analysis. Spine 1989; 14(2): 162-5.

– 2.5 degrees of rotation, 0.7 mm of translation– No difference between asymptomatic and

symptomatic joints



● Palpation-based assessment techniques are inherently unreliable

● What are the ramifications if two people can't agree on what they feel – and do so consistently?

● If there is questionable inter-rater reliability, then what is the level of validity?


Motion/Provocation

● Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S, Telje T. The reliability of selected motion- and pain provocation tests for the sacroiliac joint. Manual Therapy 2007; 12(1): 72-79.

● Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley JH, Laslett M, Bogduk N. Systematic review of tests to identify the disc, sij or facet joint as the source of low back pain. European spine journal : official publication of the European Spine Society, the European Spinal Deformity Society, and the European Section of the Cervical Spine Research Society 2007; 16(10): 1539-1550.


Repeated Movements

● Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H. Efficacy of flexion and extension treatments incorporating braces for low-back pain patients with retrodisplacement, spondylolisthesis, or normal sagittal translation. Spine 1993; 18(13): 1839-49.

● Kilpikoski S, Airaksinen O, Kankaanpää M, Leminen P, Videman T, Alen M. Interexaminer reliability of low back pain assessment using the McKenzie method. Spine 2002; 15; 27(8): E207-14.


Centralization

● Werneke MW, Hart DL, Resnik L, Stratford PW, Reyes A. Centralization: prevalence and effect on treatment outcomes using a standardized operational definition and measurement method. J Orthop Sports Phys Ther 2008; 38(3):116-25.

● Skytte L, May S, Petersen P. Centralization: its prognostic value in patients with referred symptoms and sciatica. Spine 2005; 30(11): E293-9.

● Aina A, May S, Clare H. The centralization phenomenon of spinal symptoms--a systematic review. Man Ther 2004; 9(3): 134-43.



Movement-based and provocation-based assessment techniques – reliability and validity

Centralization as a prognostic indicator

Repeated movement testing as reliable as MRI but with far less cost!


In the meantime …

What do doctors, chiropractors, massage therapists, and physical therapists continue to utilize as a primary form of assessment and upon which they base their clinical reasoning?

– Palpation-based assessment techniques


Evidence


Treatment Interventions

Perceived Causes:● Muscle imbalances● Lack of flexibility● Incorrect footwear● Leg length discrepancy● Foot structure● Too much speed work● Asymmetry and mal-alignment



Treatment Interventions:● Modalities ● Active Release Therapy/Graston ● Strain-Counterstrain● SI joint manipulation



Treatment Interventions:● Orthotics and heel lifts● Shoes● Core stabilization● Stretching● Aquajogging



Systematic reviews– Modalities (ultrasound, electrical stimulation)– Spinal manipulation– ART/Graston– Orthotics– Stretching– Core stabilization



Based on the scientific literature regarding treatment interventions, what do chiropractors, massage therapists, and physical therapists continue to utilize?


Community Standards

Accepted Community Standards Of Care(what providers and patients consider “acceptable”)

vs

Evidence-Based Standards Of Care(clinical guidelines; outcomes-driven)


Problem

ACSC and EBSC are not the same!

ACSC has unfortunately become “gold standard” with patients


Responsibility

We continue to tell payors that evidence and outcomes are important …

We continue to tell legislators that evidence and outcomes are important …

We continue to tell students that evidence and outcomes are important …


Responsibility

We continue to tell patients that evidence and outcomes are important …

Our professional association continues to advocate it ...


But In The Words Of Gandhi ...

“We must be the change we wish to see in the world”


Challenge Your Thinking!

“We can't solve problems by using the same kind of thinking we used when we created them.”

(Einstein)


For More Information:

● Smart Sport International

www.smartsport.info● Smart Life Institute

www.smartlifeinstitute.com● “Consumer's Guide To Health”

Every second Tues at 8:00pm CT

www.blogtalkradio.com/abesselink● “RunSmart: A Comprehensive Approach To

Injury-Free Running”

www.lulu.com/abesselink

http://www.smartsport.info/

http://www.smartlifeinstitute.com/

http://www.blogtalkradio.com/abesselink

http://www.lulu.com/abesselink


Photo Credits

All photos Creative Commons (Attribution-No Derivative)– #3, 14, 21, 28, 39, 94 “Evidence” on Flickr by billaday– #8 “Counterstatement to what sean calls 'evidence'” on Flickr by astera

snowwhite– #12 “Choose your evidence carefully” on Flickr by rocket ship– #49 “Il y a 60 ans, Gandhi assassiné" on Flickr by ah zut– #13, 51: Allan Besselink – All others understood to be public domain/fair use and all attempts have

been made to identify all image owners and licenses

the injured runner: an evidence-based approach. part one: running injuries

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