Presented by: Michael Fredericson, MD
Professor, Orthopedic Surgery and Sports Medicine
October 23, 2014
Because of the repetitive overload, running can lead to several common injuries to the foot, hips, and knees. Michael Fredericson, MD, a professor of orthopedic surgery and director of the Stanford Runners Injury Clinic, discussed the most common runners’ problems and scientifically based treatments at a presentation sponsored by Stanford Hospital Health Library. His lecture focused on what he referred to as the “Big Six.”
This condition is caused by overuse over time. The hamstrings run from the top of the tibia, just behind the knee, up along the back of the thigh to the pelvis. The condition causes tendon degeneration and tenderness, and the pain is worse when running, especially with faster acceleration. The tendon runs right next to the sciatic nerve, which can also become inflamed causing intense pain. The collagen fibrils comprising the tendons become disorganized, making them weak and more vulnerable to damage.
Treatment involves a series of exercises that are built up gradually to strengthen the hamstrings. Eccentric exercises that lengthen the muscles include variations of double- and single-leg bridges, Swiss ball curls, and squats, progressing slowly to build strength. His studies have found that injuries decrease when core exercises are added since these actions can reduce pelvic tilt, stabilize the pelvis, and reduce strain on the hamstrings. Dr. Fredericson recommends doing planks with leg lifts and side planks to strengthen the core, as two examples of appropriate exercises.
If strengthening exercises are not successful, several nonsurgical options are available including corticosteroid injections using ultrasound guidance to target the drug to the specific surrounding tissue without damaging the tendon itself. About half the people who chose this option see at least “moderate” resolution, he said. Another option is a platelet-rich plasma injection (PRP), which isolates the blood’s natural growth factors to stimulate the body’s natural repair system. A study is in progress to see if results from PRP are better than steroids.
When exercise and physical therapy reduces the pain and strength is close to normal, it is safe to start a gradual return to running.
Prevention: Core and eccentric exercises
PFP, also known as runner’s knee, is much like low back pain, said Dr. Fredericson—once you have it, it may never completely go away. And it is extremely common: About 25 percent of running injuries are patellofemoral pain injuries, and a recent study found that more than $8.3 billion was spent on treating the condition in the U.S.
PFP is caused by increased stress on the joint and cartilage on the underside of the patella (kneecap). The patella travels within a groove in the femur, where it slides back and forth when the knee is flexed or bent. It’s more common in women and can be caused by abnormal alignment of the patella, poor foot positioning while running, and abnormal pelvic mechanics.
Dr. Fredericson has conducted weight-bearing studies using MRI and CT imaging on athletes with runner’s knee and found that the femur rotated underneath the kneecap, causing the pain. Additional studies have found that runner’s knee was improved by strengthening the muscles at the hip, correcting the medial femoral rotation.
Several studies have found that strengthening the hip muscles decrease the pain and improve alignment. A regimen of isotonic/ isokinetic exercises should be adopted to help build endurance as well as strength, such as squats and balance training, starting slowly and eventually building up to pylometrics (jumping). For many people, once mechanics have been rectified in the gym does not mean they are being applied during running, so use a buddy, coach, or a treadmill with a mirror to build consciousness and new running form. Dr. Fredericson also suggested using a forefoot strike pattern to reduce peak force to the patellofemoral joint.
Prevention: Squats and hip abductor exercises
Iliotibial Band Syndrome
The most common cause of lateral knee pain in runners is an overuse injury of the tissue that runs on the outside of the leg from the hip to the shin. It’s caused by an inflammation of the tissue as it rubs against the outer knee bone. The biomechanics of the hip muscles control the knee movement, causing pain over long distances or downhill running.
Initial treatment should be the use of foam rollers, myofascial massage, and stretches to release muscle tightness. Hip abductors including the gluteus medius should be strengthened, starting with side leg raises, and working up to lunges and single-leg squats. A study of distance runners found that developing hip strength returned them to normal range within six weeks. When these methods don’t help, an injection at the point of inflammation can be applied.
For this injury, runners should focus on starting with faster running speeds, then gradually build up their distance.
Prevention: Side leg lifts and foam rollers
Shin splints, or medial tibial stress syndrome, are caused by small tears or inflammation in the muscles at the tibia, while stress fractures occur in the bone itself. They are most common in women, inexperienced runners, those with high body mass, or runners with excessive pronation. They are often a sign that you have done too much, too quickly.
Proven treatments include ice massage; iontophoresis, phonophoresis, and extracorporeal shockwave therapy. Compression socks, leg braces, and pulsed electromagnetic field therapy have not been shown to improve the condition.
Studies have shown that using an anti-gravity treadmill can reduce stress to the tibia. People with shin splints tend to run with a stiff knee so try land with the knees bent to promote a softer landing and incorporate greater hip movement to help dissipate the energy, Dr. Fredericson said. A forefoot strike pattern can also help to lower the loading rate, and deep water running can be beneficial. Increase your cadence to 90 revolutions per minute, and your body will naturally get to its best foot strike, he said.
Prevention: Gait modification
Achilles tendonitis is often caused by doing too much too soon. It’s a common overuse injury that can lead to small tears within the tendon if not addressed. Runners often develop symptoms of Achilles tendonitis after increasing their mileage or changing their terrain.
More common in men than women, the condition causes a thickened, nodular tendon and weakened tissue. Strengthening the muscle using eccentric exercise every day will help to normalize the area but may take up to three months for results to show.
For more advanced cases, extracorporeal shock wave therapy (ESWT) can be used to deliver focused shock waves, creating a microtrauma to the area that stimulates the body’s natural healing response. A study found that response to ESWT and a regimen of exercise was identical, and Dr. Fredericson said that another study found a combination of the two therapies would provide improved results from either treatment alone. A low-strength nitroglycerin patch provides improved blood flow to promote more rapid healing to the damaged tissue.
Prevention: Calf-lowering exercises
Plantar fasciitis is one of the most common causes of foot pain. It involves discomfort and inflammation of the plantar fascia, which runs across the bottom of the foot, connecting the heel bone to the toes. If not addressed, over time the tendons can become chronically scarred, so it should be treated in the early stages of inflammation.
Since there are so many treatment options, Dr. Fredericson did a study to identify evidence of results, rating them as high, medium, and low. Overall stretching with massage showed the best results in the early stages, but the key is to stretch the plantar fascia, not just the Achilles, and to do the stretches at least five times a day for at least 30 seconds. Pool running and swimming can help keep pressure off your feet. Heal cushions and arch taping rated medium, and anti-inflammatories had low impact.
Chronic cases are sometimes treated with cortisone injections or shockwave therapy (high), night splints (medium, especially for people who feel pain with the first steps in the morning), or acupuncture (low, because studies have not been conclusive). Other strategies include custom orthotics (medium) and PRP (low).
Prevention: Run barefoot
About the Speaker
Michael Fredericson, MD, is a professor of orthopedic surgery and sports medicine, and director of Stanford’s Runner’s Injury Clinic. He is also the team physician for Stanford’s track & field, swimming, diving, and softball teams. His research focuses on the prevention and treatment of sports injuries, with a special interest in running athletes. He received his MD from New York Medical College, completed his residency at Stanford, and did his fellowship at Sports Orthopedic and Research Associates. He is board certified by the American Board of Physical Medicine and Rehabilitation with subspecialty certification in sports medicine. He is a senior founding editor of the PM&R Journal, a scientific advisory board member for Runner’s World Magazine, and is listed in Best Doctors in America and Who’s Who in Medicine in America.