INTRODUCTION
Long distance running has become a popular sporting activity, with millions of recreational runners around the world. However, the risk of sustaining a running-related injury (RRI) is high; literature shows up to an 80% incidence of RRIs worldwide. While injuries to runners are rarely severe, they can be frequent and persistent, requiring medical treatment associated with high treatment costs.

Researchers in the study, Analysis of Running-Related Injuries: The Vienna Study, looked at training, footwear, anatomic malalignment, and injury data from 178 injured runners in a case-controlled, retrospective format. The researchers’ goals were to present injury data from a running population, investigate different running footwear categories and specific injuries, and analyze a broad range of potential contributing factors for the most common RRIs.

METHODS
Injured runners were recruited at an orthopedics practice in Vienna, Austria, during a three-year period. Patient examinations were performed by a sports medicine surgeon. The participants completed a questionnaire which included footwear and training data followed by the examiner performing a subjective history, anatomical assessment, and a physical examination of the injured area.

The anatomical assessment included inspection of the spine, pelvis, knee, ankle, and foot for malalignment. An injury was considered a RRI if the patient had pain or symptoms during or immediately after a running session, the pain was significant enough to keep the runner away from training for more than three days, and the patient sought medical assistance. Following data collection, the researchers analyzed the results to observe for any correlations among the variables.

RESULTS
FOOTWEAR:
All but one participant able to name brand of shoe
Fewer than half (45%) were able to name the specific shoe model
Only 39 % of patients with pes valgus used a motion-controlled running shoe despite wide spread literature recommendation that this type of shoe corrects foot malalignment
ANATOMIC MALALIGNMENTS (PERCENTAGE OF PARTICIPANTS WITH MALALIGNMENT):
Varus knee: 83.1%
Pelvic obliquity: 80.8%
Patellar squinting: 52.2%
Pes cavus: 5%
Pes plans: 34.8%
Scoliosis: 31.4%
Pes valgus: 3%.
INJURY ANALYSIS:
All seven injuries recorded were overuse injuries
Body part most injured was the knee (41%), followed by the ankle (15%), and the foot (11%).
The five most common injuries were:
Patello-femoral pain syndrome (PFPS) (13.4%)
Iliotibial band friction syndrome (ITB) (12.3%)
Patellar tendinopathy (12.3%)
Spinal injuries (11.2%)
Ankle instability (8.4%).
DISCUSSION AND ANALYSIS OF RESULTS:
BMI: Patients with spinal injuries tended to have higher BMIs while lower BMI was observed in patients with knee injuries, ITBFS, and patellar tendinopathy.

Injury History: A prior history of injury was associated with an increased risk of reinjury. Injury history contributed mainly to knee injuries. Twenty out of 21 patients with ITB friction syndrome presented a history of similar complaints.

Training History and Load: While higher overall training load seemed to protect against PFPS and patellar tendinopathy, higher training load was positively associated with injuries of the lower leg and ankle instability. While a higher training load can signal greater experience, less training errors, and more efficient anatomical adaptation, higher training load can also result in a higher degree of fatigue and altered kinematics.

Footwear Analysis: Researchers were surprised there was a lack of knowledge regarding the type of running shoe the participants used. Researchers note that this finding could be lack of awareness or not of great importance, especially in more novice runners. In addition, the study results show the proportion of patients with pes valgus who wear a motion-controlled shoe is low. Shoe wear that corrects pes valgus has been controversial in recent literature so this finding could lead to ongoing discussion.

ANATOMIC MALALIGNMENT ANALYSIS
Spine and Pelvic Malalignment: The authors found that scoliosis was positively correlated with lower back, hip, and pelvic injuries. Although a leg length discrepancy can cause a pelvic tilt and secondary scoliosis, it was not associated with any specific injury.
Knee: Malalignment of the knee included all patella anomalies, ligamentous or general instability, and shortening of the thigh muscles. There was a positive association of knee malalignment with injuries in the patellofemoral joint. Also, a lower training load will likely result in weaker active and passive stabilizers of the patellofemoral complex exposing the runner to a higher risk of suffering PFPS.
Leg Axis: The researchers observed the highest incidence of the varus knee in patients diagnosed with knee injuries. The varus knee alignment induces higher stresses in the lateral musculature and stresses in the medial aspect of the knee as well as the mistracking of the patella, which would coincide with the reported pathologies.
Foot Malalignment: Excessive foot pronation and associated higher lower limb rotation in runners with pes planus is considered to be associated with PFPS and stress fractures. This study revealed a correlation with present pes planus deformity and knee injuries. Interestingly, pes planus was protective of foot/ankle injury. As expected, pes cavus was associated with ankle instability.
CONCLUSIONS:
In conclusion, RRIs are multifactorial and are associated with personal data, training load, anatomic malalignments, and injury history. In general, runners at a high risk of injury could be identified from a patient-specific training profile and running form as well as from pre-existing malalignments such as scoliosis, knee malalignments, and/or varus knee and. Identification of runners at high risk of injury can help therapists to introduce an appropriate and balanced training adaptation.

Furthermore, awareness of injury risks and prevention should be raised in running schools and by medical specialists. The authors strongly recommend further studies focused on specific injuries in combination with related malalignments and detailed training habits, in addition to research on running-related injuries as a generalized pathology.

CLINICAL IMPLICATIONS AND PHYSICAL THERAPY FIRST
The therapists at Physical Therapy First have extensive experience in evaluating and treating runners. Come see us if you run for fun or are training for an upcoming race. We can determine your risk for sustaining an RRI and create an individualized training program to keep you on track to maintain a healthy running lifestyle.

REFERENCE
Benca, E., Listabarth, S., Flock, F., Pablik, E., Fischer, C., Walzer, S….Ziai, P (2020). Analysis of Running-Related Injuries: The Vienna Study. Journal of Clinical Medicine. 9, 438.

The labrum is a fibrocartilaginous ring that wraps around the glenoid, or the “socket” of our shoulder. It deepens the socket about 50% in order to improve congruency of the humeral head, or the “ball” into the glenoid (socket). It also serves as an attachment site for our shoulder ligaments and some tendons, making this structure a vital component of shoulder stability. For people with excessive motion at the shoulder or generalized hypermobility, it can cause increased amount of shear forces to the labrum making this structure prone to injury. Labral injury can occur as tearing or as a detachment from the glenoid; and can happen traumatically or over time. The two most common labrum detachment injuries are termed SLAP lesions and Bankart lesions based on the location of the detachment.

For those with a known or possible labrum pathology, surgery may be a viable option in order to stabilize the shoulder and repair a labral tear. However, it may be better for initial treatment of any shoulder instability to be in a non-operative manner. Non-op rehab for labral tears will focus on decreasing pain and modifying provocative activities. Exercises will focus on improving the strength and endurance of the rotator cuff and scapular musculature. The goal is to improve the neuromuscular control of the shoulder complex in order to stabilize the shoulder using the muscles around it.

The following is one study that discusses non-operative outcomes of SLAP labral tears. In this study, 39 individuals who met the criteria were followed. Out of all the individuals, 51% of subjects opted for surgery while the others remained in non-op management. The non-op management group received non-steroidal anti inflammatory drugs (NSAIDs) and a physical therapy program focused on scapular stabilization exercises along with posterior capsule stretching. This study utilized patient reported questionnaires that measured functional abilities, pain scales, and quality of life to determine the effectiveness of non-operative vs operative management to treat a SLAP labral tear.

After a three year follow-up, those that stayed with non-operative management had significant improvements in pain, functional activities, and quality of life. They also had comparable outcomes to the surgery group in returning to sport, however returning to overhead sports was more difficult. This study shows that some patients can have successful outcomes of a SLAP tear even without surgical interventions and the fact that it is a 3 year follow up indicates long term results are positive which may arguably be more meaningful for patients. However, non-operative management is not appropriate for everyone. In this study, those that opted for surgical intervention was due to failure to improve and still showed positive outcomes as well. Based on results from this study, it is best for those with SLAP labral tears to trial a course of non-conservative management first before considering surgical intervention. This also stresses the importance of a healthcare team of surgeons and physical therapists working together to make the best recommendations for each patient. Each patient is different and each patient’s current clinical presentation, functional deficiencies, and goals need to be taken into account when making this decision.

At Physical Therapy First, we look at all parts of the patient and take into account all of their needs. We are able to spend one hour of direct 1 on 1 time with each of our patients. This is unique and rare in outpatient orthopedic physical therapy. It allows us to perform more thorough evaluations, look into different parts of the body, and be able to work toward individualized goals in a more specific manner. If you have a known diagnosis of a labral tear, it is recommended to give physical therapy a try before looking into surgical options. Or, if you have been experiencing shoulder pain and not sure why, we can perform an examination and determine what the best care moving forward is. We will make sure to work with you and monitor your progress to make the most appropriate recommendations.

References:

Ellenbecker, T., Manske, R., Kelley, M., 2016. Current Concepts in Orthopaedic Physical Therapy The Shoulder: Physical Therapy Patient Management Using Current Evidence. Orthopaedic Section APTA

Edwards, S., Lee, J., Bell, J., Packer, J., Ahmad, C., Levine, W., Bigliani, L. and Blaine, T., 2010. Nonoperative Treatment of Superior Labrum Anterior Posterior Tears. The American Journal of Sports Medicine, 38(7), pp.1456-1461.)

INTRODUCTION
The gluteal muscles are arguably the most important muscles for runners in terms of strength and activation. The gluteal muscles consist of the gluteus maximus, gluteus medius, and gluteus minimus. These muscles work as a group to prevent femoral adduction and internal rotation, which have been linked to an increased risk of injury in the early stance phase of running. Weakness or dysfunction of the gluteal muscles in runners has been shown to contribute to many musculoskeletal disorders including low back pain, patellofemoral pain syndrome, and iliotibial band syndrome, to name a few.
The authors in a recent study, Comparative Analysis of Hip Muscle Activation During Closed-Chain Rehabilitation Exercises in Runners, looked at the effectiveness of three rehabilitation exercises (bilateral hip external rotation, forward lunge, and single leg squat) designed to stimulate the demands of the gluteals during running. The authors hypothesized there would be greater gluteal activation during the forward lunge compared to bilateral external rotation and single leg stand seeing as that exercise was the most similar to running.

METHODS
Twenty-two healthy runners performed three gluteal strengthening exercises while electrodes recorded peak amplitude of muscle activity. The researchers measured the peak amplitude of muscle activation during the concentric (muscle shortening) and eccentric (muscle lengthening) phases of the exercises and compared it to the runners’ peak muscle activation during the stance phase of running.

CONCLUSION
All three of the exercises showed the same peak amplitude during the eccentric phase. The bilateral external rotation elicited significantly reduced amplitude than the squat and lunge activity during the concentric phase of the exercise. The exercises investigated in this study were less than 70% of the peak activation levels obtained with running.

CLINICAL GUIDELINES
Because of the high prevalence of running-related injuries, and the potential of gluteal strengthening and activation in reducing these injuries, it is important to identify exercises which activate these muscles similarly to how they are used in runners. This was one of the first studies observing muscle activity during functional exercises. Although none of the exercises investigated in this study approached the peak activation levels obtained with running, the results indicate that the forward lunge with resistance band and single leg stand were superior to the bilateral external rotation exercise for concentric activation of the gluteus maximus and medius.
In theory, a progression of these exercises from clamshell to single leg rotational squat, to forward lunge could be beneficial in activating and strengthening gluteal muscles in a runner. More research is needed to identify different functional activities specific to runners.

PHYSICAL THERAPY FIRST IMPLICATIONS
Similar exercises as those measured in the study are common for physical therapists to give as part of an individualized home exercise program. Our team continues to stay up to date on the latest research in order to provide our clients with an evidence-based approach to therapy. The exercises measured in the study successfully activated the gluteals in an eccentric manner and thus performing these regularly could help to decrease a runner’s risk for developing a running-related injury.

FUNCTIONAL EXERCISE PROGRESSION FOR GLUTEAL STRENGTHENING IN RUNNERS
1. Bilateral Clamshell

2. Single-leg rotational squat

3. Lunge with Resistance Band

REFERENCE
Connelly, Chrostopher., Moran, Matthew., Grimes, Jason (2020). Comparative Analysis of Hip Muscle Activation During Closed-Chain Rehabilitation Exercises in Runners. International Journal of Sports Physical Therapy. Vol 15, Number 2: 229-237

INTRODUCTION
Patellofemoral pain syndrome (PFPS) is a common source of knee pain in the physically active population and one that we treat at Physical Therapy First regularly. PFPS occurs more in females than males with a ratio of 2:1. This syndrome presents as pain in the anterior part of the knee, around the kneecap, and can occur on one or both sides of the body. It is commonly an overuse injury and has been linked to impairments of the quadriceps muscle. In the study Hip Strengthening Prior to Functional Exercise Reduces Pain Sooner Than Quadriceps Strengthening in Females with Patellofemoral Pain Syndrome: A Randomized Clinical Trial, the authors address the hypothesis of early proximal hip strengthening versus quadriceps strengthening for the treatment of PFPS.

METHODS
Thirty-three women with unilateral or bilateral patellar pain were included in the study and given the visual analog scale (VAS) as a pain scale and the Lower Extremity Functional Scale (LEFS) as a measure of function. Objective measures including isometric hip abduction, hip external rotation, and knee extension were taken using a hand held dynamometer. Functional strength was also assessed using an anterior step-down test for the number of repetitions in a 30 second period of time.

Participants were divided into hip or quadriceps strengthening program and performed rehabilitation exercises three times a week for four weeks in addition to a common stretching program. Both groups then performed the same exercises for weeks four through eight which focused on functional weight-bearing and balance training.

After the eight weeks of training, participants were given the VAS and LEFS and their strength was re-measured.

RESULTS
The results showed significantly less pain in the hip strengthening group compared to the quadriceps group at four weeks as reported on the VAS. Pain scores at four and eight weeks were significantly lower than baseline scores in the hip group. Scores for the quadriceps group were significantly lower at the eight-week time point but not at the four-week point compared to baseline.

Both groups significantly improved on the forward step-down test. Hip abduction strength significantly increased in the hip group from weeks zero to eight but not in the quadriceps group. Hip external rotation strength increased over the 8-week period in both groups. Knee extensor strength did not improve in either group over time.

DISCUSSION
The purpose of this study was to compare initial hip strengthening to initial quadriceps strengthening in the treatment of females with PFPS. It was hypothesized that rehabilitation initially focusing on isolated hip strengthening would result in less pain, more strength and function, and better preparation for functional exercises than initial quadriceps strengthening. While both groups experienced similar overall increased strength and function, the hip group reported less pain than the quadriceps group after the first four weeks of rehabilitation.

The most significant finding of the study was the decreased pain reported at week four in the hip strengthening group, which decreased by 43%. Both hip and quadriceps strengthening led to increased function over time as measured by the forward step-down test.

The authors found it interesting that there were no improvements in quadriceps strength in this group. The authors proposed this finding could be due to pain preventing adequate muscle activation.

LIMITATIONS
One limitation in this study includes the varying amount of pain reported by the participants; some had minimal pain with activity and others had a higher degree which severely limited their function. Additionally, the study only looked at women and was only performed for an 8-week time period so it cannot be generalized to men with this syndrome or show long term effects

CONCLUSIONS AND PTF IMPLICATIONS
The main conclusion in this article shows that focusing on a proximal hip strengthening program is more efficient in decreasing pain and increasing hip strength than quadriceps strengthening program in the treatment of PFPS.

PFPS is a diagnosis that we commonly see at Physical Therapy First and our therapists are able to create an individualized treatment program which includes proximal hip strengthening for the treatment of patellar pain.

Dolak, K., Silkman, C., Medina McKeon, J., Hosey, R., Latterman, C., Uhl, Timothy (2011). Hip Strengthening Prior to Functional Exercises Reduces Pain Sooner Than Quadriceps Strengthening in Females With Patellofemoral Pain Syndrome: A Randomized Clinical Trial. Journal of Orthopaedic & Sports Physical Therapy: Vol 41, 8: 561-570.

BACKGROUND:
A concussion is a type of traumatic brain injury caused by a bump, blow or jolt to the head or by a hit to the body that causes the head and brain to move rapidly back and forth. This sudden movement can cause the brain to move in the skull, creating chemical changes and sometimes stretching or damaging brain cells. Concussions are a common sports injury and most people recover in 7-10 days, but some continue to have persistent symptoms. Two of the most frequently reported symptoms are headache and dizziness, followed closely by nausea and neck pain. Cervical spine trauma may cause prolonged post-concussion headaches. Upper cervical spine dysfunction can cause cervicogenic headaches while dizziness and balance deficits may be due to dysfunction of the vestibular, proprioceptive or central system.

PARTICIPANTS:
29 participants total
-14 participants in the control group
-15 participants in the treatment group

METHODS:
The participants were randomly allocated to the control group or the treatment group. Participants attended physical therapy once per week for 8 weeks. Both groups performed non-provocative range of motion exercises, stretching and postural education by the same physical therapist. Then the intervention group was instructed by another physical therapist for a combination of cervical spine physical therapy and vestibular rehabilitation. The primary outcome measure was number of days from treatment initiation until medical clearance to return to sport.

RESULTS:
Eleven of the 15 participants in the treatment group were medically cleared to return to sport within 8 weeks of treatment. Only 1 of the 14 participants in the control group was medically cleared to return to sport within 8 weeks of treatment. Individuals in the treatment group were 10.27 times more likely to be medically cleared to return to sport as compared to the control group.

CLINICAL APPLICATION:
Here at PTF we will complete a thorough evaluation to determine the origin of the symptoms each patient is experiencing. We will then create a comprehensive treatment plan based on our findings and each patient’s goals. In patients with post-concussion symptoms, we will work to combine cervical spine treatment with vestibular rehabilitation which may facilitate recover and decrease time lost from sports.

ORIGINAL ARTICLE:
Schneider, K. J., Meeuwisse, W. H., Nettel-Aguirre, A., Barlow, K., Boyd, L., Kang, J., & Emery, C. A. (2014, September). Cervicovestibular rehabilitation in sport-related concussion: a randomized controlled trial. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/24855132