Long distance running - injuries and prevention
Since its conception in 1980, The London Marathon has a lot to answer for! Whilst it has not quite reached the referral rates that the skiing season provides, physiotherapy departments will inevitably end up treating a significant number of patients during the first half of the year who are in training for or who are suffering the consequences of running the marathon.
Apart from the odd fall that may be sustained during training, all musculoskeletal injuries seen are chronic in nature and will be the result of repetitive loading. This article intends to look at common exacerbating factors, a couple of injuries seen in the lower limb and lastly unravel the term “shin splints”.
Exacerbating factors
Biomechanics – If the lower limb is not propelling the body or absorbing shock as efficiently as possible, it is likely that a structure will be overloaded, become fatigued and injury the result. The most common biomechanical anomaly is pronation and this can lead to increased tension in the planter fascia and tibiallis posterior tendon, or it can lead to posterolateral impingement of the peroneii tendons. Higher up the leg, excessive pronation will cause medial rotation of the tibia and effect patella tracking and can also increase tension in the iliotibial band (see below)
Muscle balances – This is closely linked to the biomechanics and the style of running. It is an important factor to consider – in the same way as foot posture can influence lower limb joint alignment, poor local muscle control will affect the stress placed on joints and other structures during the gait pattern. Global stability should also be considered, as the foot provides distal control, the muscles around the pelvis and spine will provide proximal stability – the better control you have of your central core the more effective you will be in throwing, kicking and propelling your body.
Training – Too much too often is a recipe for disaster as is too much too late, as is no training! Quite simply we are not designed to sit at desks all week and then go and run 26 miles with improper preparation, let alone whilst dressed as a penguin and juggling – enough said!
Equipment / surfaces – Supportive shock absorbent footwear is essential. With regard surfaces runners should watch out for excessive camber in the road and they should avoid changing surfaces.
Anterior knee pain
This is often patello femoral in origin and due to maltracking of the patella in the femoral groove. Contributory factors can include foot biomechanics and local muscle imbalances (see above). For example if the runner has a weak and inefficient vastus mediallis and tight lateral structures, there will be rotation of the patella resulting in increased pressure through the inferomedial facet. Other muscle influences on the patella will result from tightness in the quadriceps and / or gastrocsoleal complex.
Iliotibial band friction syndrome (Runners knee)
This condition only affects sports people who perform a repetitive action. It is an inflammatory response that builds up due to friction between the lateral femoral condyle and the iliotibial tract. The runner will present with pain that starts during activity and gradually increases. The pain will linger for several hours post exercise and may be amplified when using stairs. Again the exacerbating factor is likely to be mechanical. If the foot excessively pronates, increased medial rotation of the hip will result and increased tension in the iliotibial tract will occur. This condition is also common in patients who run on a cambered surface. Treatment will involve addressing the biomechanics and muscle imbalance as well as using modalities to resolve inflammation.
Shin splints
This is one of those umbrella diagnoses. Below I have highlighted three differentials that need to be made to ensure that appropriate advice and treatment is given.
1. Medial tibial stress syndrome - This usually presents as a wide spread ache over the inner border of the shinbone. It will be brought on after a period of impact related exercises, especially if the exercise is performed with a repetitive action on a hard surface e.g. jogging and basketball and is often related to having inefficient mechanical alignment in the foot and ankle. It effectively is inflammation of the periosteal membrane and is thought to be a result of excessive pull of the crural muscles at their attachment to the tibia. Again exacerbating factors are the biomechanics and increased tension in the deep crural muscles. Physiotherapists can address tissue tension and can advise, sometimes in conjunction with a podiatrist, as to the provision of orthotics.
2. Stress fractures. These present as a much more specific pain with focal tenderness. The site can be either on the side or front of the tibia or on the fibula. Again these usually occur in sports people whose activities are repetitive and again they can be related to inefficient mechanics in the foot and ankle. A stress fracture can often occur as a follow on to medial tibial stress syndrome if the patient does not rest appropriately. The treatment is similar to above, but the length of rest is likely to be longer.
3. Compartment syndrome. This can present as a diffuse ache anywhere in the shin. It will worsen with activity though unlike the others the activity does not have to be repetitive, so sports people who use multidirectional movement such as footballers and hockey players can be affected as well as the repetitive motion runners. The muscles in the shin are compartmentalised and bounded by fascia, during exercise the muscle expands which will cause an increase in pressure in the compartments resulting in pain. Diagnosing this condition has become easier with the arrival of pressure testing. This procedure involves a pressure catheter being inserted into the compartments and the patient is then asked to run on a treadmill. The pressures can then be assessed. In my opinion the best treatment for this condition is surgery and the outcomes are usually excellent. Physiotherapy does not have a role until the postoperative stage.