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The Benefit of Osteopathic Manipulative Therapy During Pregnancy

by | Aug 17, 2020 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction

Back pain is a commonly reported symptom among pregnant women, especially those in the third trimester. This pain can lead to a temporary disability, sleep-disturbance, and may affect daily living and quality of life. Many women seek physical therapy, chiropractic care, massage therapy, and acupuncture treatment to manage their symptoms. The researchers in the study, Osteopathic Manipulative Treatment of Back Pain and Related Symptoms During Pregnancy: A Randomized Controlled Trial, looked at the effects of osteopathic manipulative treatment (OMT) on pain and function in pregnant women during the third trimester.

Materials and Methods

144 pregnant women between 28- and 30-weeks gestation were enrolled in the study and randomly assigned to one of three groups. The first group was usual obstetrical care (UOBC), the second group was usual obstetrical care and OMT (UOBC+OMT), and the third was usual obstetrics care and sham ultrasound treatment (UOBC+SUT). Each treatment group received seven, thirty-minute treatments spanning nine weeks in addition to their regularly-schedule obstetrics care. The two outcome measures utilized in this study included back pain, as measured on ascale from 0 to 10 and back-related function, measured by the Roland-Morris Disability Questionnaire.

The subjects assigned to the UOBC only group did not receive any treatments beyond conventional obstetrical care; however, they were expected to complete data collection forms on the same schedule as all other trial subjects. In group two, the OMT was performed by a licensed physician and included soft tissue, myofascial release, muscle energy, and range-of-motion mobilization. The physician performed these interventions to treat somatic dysfunction of the cervical, thoracic, and lumbar spine; thoracic outlet and clavicles; ribcage and diaphragm; and pelvis and sacrum. The study protocol prohibited use of high velocity, low amplitude (HVLA) techniques because the increasing ligamentous laxity that occurs in late pregnancy may pose a theoretical risk in performing such maneuvers. In group three, SUT used a nonfunctional ultrasound therapy unit that was modified for research purposes to provide both visible and auditory cues that could potentially elicit a placebo response.

Results

A total of 49, 48, and 49 subjects were randomized to the UOBC+OMT, UOBC+SUT, and UOBC only groups, respectively. Subjects in the UOBC only group had the highest appointment attendance rate, while those in the UOBC +SUT group had the lowest appointment attendance rate.

Although there were no statistically significant differences in pain levels among treatment groups, mean pain levels decreased in the UOBC+OMT group, remained unchanged in the UOBC+SUT group, and increased in the UOBC only group. There were significant differences in back-related function among treatment groups. Back-related function deteriorated less in the UOBC+OMT group than in the UOBC only and UOBC+SUT groups. These outcomes suggest OMT could offer a clinical benefit when provided as complementary therapy to usual obstetrical care.

Discussion

The study results indicate that OMT lessens or halts the deterioration in back-related function that often characterizes the third trimester of pregnancy. While there is evidence that OMT may provide an important clinical benefit in reducing back pain, the results are not as conclusive as they are for back-related function. Thus, taken together, these findings suggest that the beneficial effects of OMT on physical functioning during the third trimester of pregnancy may not be related simply to an analgesic effect on back pain, but may possibly involve other mechanisms.

Limitations

There were a few limitations in this study. The first was the method of blocked randomization which did not adequately randomize subjects based on illicit drug use, vaginal bleeding, and race/ethnicity. In addition, the OMT protocol was limited to the third trimester of pregnancy. Theoretically, in clinical practice, it would be desirable to implement OMT earlier in the pregnancy to prevent or slow the progression of somatic dysfunction and back-related symptoms. Finally, the OMT protocol involved a standardized approach to treatment which may not adequately reflect the potential benefits seen in clinical practice, where there is a more individualized treatment approach for each patient.

Conclusions and Physical Therapy First Implications

The study results indicate that a larger Phase III trial with greater statistical power and better control of potential confounders is warranted to better assess the effects of OMT on back pain and related physical functioning during the third trimester of pregnancy. At Physical Therapy First, our therapists are proficient at performing the interventions used in this study including soft tissue, myofascial release, muscle energy, and range-of-motion mobilization. If you are pregnant and have experienced back pain at any point during your pregnancy, physical therapy is a great intervention for managing pain and improving function.

Reference

Licciardone, John., Buchanan, Steve., Hensel, Kendi., King, Hollis., Fulda, Kimberly., Stoll, Scott (2010). Osteopathic Manipulative Treatment of Back Pain and Related Symptoms during Pregnancy: A Randomized Controlled Trial. American Journal of Obstetrics and Gynecology. 202(1): 43.e1–43.e

 

Effects of Different Exercise Interventions on Risk of Falls, Gait Ability, and Balance in Physically Frail Older Adults: A Systematic Review

by | Aug 12, 2020 | Health Tips

By Lisa Jerry, SPT

Introduction

Frailty is a syndrome that can accompany increased age, especially in individuals over the age of 65, that decreases the body’s functional capacity to handle stresses. Frailty increases an individual’s risk of disability, falls, and hospitalization. Several issues associated with frailty include weight loss, decreased muscle strength, decreased endurance activity, and slower walking speed. This systematic review aims to look at the benefits of several different types of training and their impact on frailty, as prescribed by a Physical Therapist (PT).

Methods

20 randomized controlled trial studies had their data combined which focused on strength training, endurance training, balance training, and multi-component exercises (a combination of all three of these trainings). These studies described their participants as frail, pre-frail, elderly individuals with a history of falls, and recent illness-induced functional decline.

Types of Exercise Interventions

Strength training: Strength training is a common intervention utilized to counteract the changes that occur due to aging. Strengthening the hips and knees is a good foundation for these exercise programs looked at in the studies. Overall consensus between these studies was that strengthening these groups 3 times per week, 3 sets of 8-12 reps, and increasing resistance over time showed overall positive improvements in gait, stairs, and muscular strength.

Endurance training: Aging decreases the cardiovascular system’s capacity, making everydays tasks harder to perform. Different types of endurance activities that have proven to be effective include walking at different speeds, treadmill walking, stair climbing, and stationary cycling. The principle “start low and go slow” is an important principle during endurance training, so it is beneficial to start at just 5-10 minutes of endurance training at first and slowly progress up to 30-60 minutes.  It is important to consult with your physician before beginning a new exercise program.

Balance training: The best way to improve balance is to work on balance! There are countless balance interventions used during these studies including: walking in a straight line, stepping practice, throwing and tossing a ball, changing the surface a person stands on, and Tai-Chi. One study showed that 15 weeks of Tai-Chi reduced the risk of falls by 58%. Similar to the other two training types, balance training should start easier and safely progress into the more challenging activities as tolerated.

Multi-component exercises: This type of training encompasses all three of the interventions mentioned above. Targeting several different training types will allow the body to better adapt to stresses placed on it. One study found that 12 weeks of multi-component exercises resulted in an increase in strength by 75% as well as 25% fewer falls in the frail population. Another study showed that 1 year of this type of program resulted in 40% fewer falls.

Conclusion and PTF Implications

This review shows that a combination of strength, endurance, and balance training increases strength and decreases the fall risk, thus improving quality of life. Here at Physical Therapy First, we listen to each individual and what they want to improve upon. We use our knowledge and experience to create a unique progressive training program that is right for each individual to help them get back to doing what they love.

Original Article

Cadore EL, Rodríguez-Mañas L, Sinclair A, Izquierdo M. Effects of different exercise interventions on risk of falls, gait ability, and balance in physically frail older adults: a systematic review. Rejuvenation Research. Vol 16, Number 2, pages 105-114.

The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective

by | Aug 10, 2020 | Health Tips

By Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction

In physically active individuals, the knee is the joint in the lower extremity which sustains the highest percentage of injuries. Research conducted over the last several decades suggests that knee injury may have proximal influence from the hip and trunk. The authors of the commentary, The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective, provide a literature review on this topic, specifically addressing common knee injuries such as anterior cruciate ligament tear (ACL tear) iliotibial band syndrome (ITBS), and patella-femoral pain (PFP) and the role of the hip and the trunk in these injuries.

Proximal Contributions to Abnormal Tibiofemoral Joint Kinetics

During the stance phase of running and jumping, the femur adducts, internally rotates (IR), and flexes at the hip joint. These motions are primarily controlled by the hip extensors, abductors, and external rotators. Excessive femoral motion into flexion, IR, and adduction places abnormal stresses at the tibiofemoral joint.

In the presence of proximal hip weakness, some compensatory strategies of the pelvis and altered movement patterns of the lower extremity occur. The first compensatory strategy is in the presence of hip abductor weakness, the contralateral pelvis drops (Trendelenburg sign). This compensation causes increased strain to be placed on the iliotibial band and lateral collateral ligament. In compensated Trendelenburg, where the trunk leans over the stance limb, the stress is shifted to the medial knee, particularly the ACL and medial collateral ligament. The second compensatory strategy is in the presence of hip extensor weakness, a posterior trunk lean is common. This places stress through the anterior knee, possibly leading to quadriceps muscle strain, patella tendinopathy, patellofemoral joint compression, and ACL strain.

Tibiofemoral Joint Injury Mechanisms

ACL tears are one of the most common knee injuries sustained by individuals who engage in athletic and recreational activities. The rate of ACL tears is significantly higher in women, possibly due to the predisposed factor of a wider pelvis which causes an increased Q-angle at the knee. The Q-angle is the angle of the patella in relation to the pelvis and the tibia. Several studies have reported that reduced hip strength is related to greater knee valgus angles. Weakness of the hip extensors and abductors has been theorized to play a role in increased risk of females sustaining an ACL injury, however, the finding is not consistent across all studies. Additional factors, such as impaired motor control, may play a role with respect to movement pattern that are thought to be associated with ACL injury.

ITBS is a common cause of lateral knee pain and is the second most common overuse injury in runners, behind PFP. The strongest predictors of athletes who develop ITBS are excessive hip adduction and knee IR with running due to the increased stress on the lateral knee with these motions. In addition, studies show that hip abductor strength of the involved limb in runners with ITBS was significantly reduced when compared to the noninvolved limb and the control groups.

Patellofemoral Joint

PFP is the most prevalent lower extremity condition seen in orthopedic practice and has been cited as the most common overuse injury in persons who are physically active. Females with PFP tend to have excessive IR of the femur and a greater dynamic Q-angle during running. This increased angle on the knee displaces the patella medially and increases the pressures within the patellofemoral joint.

Those with PFP tend to exhibit impaired strength of the hip extensors, abductors, and external rotators. Despite the fact that altered hip motion and diminished hip strength are common findings in females with PFP, only two studies have evaluated hip strength in conjunction with hip kinematics in this population. One study reported significant reductions in isometric hip external rotator and hip abductor strength in females with PFP compared to a control group, but no differences in hip adduction and internal rotation motion during stair descent were observed. A second study reported that females with PFP exhibited diminished hip muscle strength, but only isotonic hip extension endurance was found to be correlated with excessive hip internal rotation during running.

Pelvis and Trunk Stability

The hip abductor muscles are important to maintaining the pelvis level in the frontal plane. In theory, improving performance of the hip abductors would result in a more optimal alignment of the pelvis during single-limb activities and, in turn, protect the knee joint from excessive frontal plane moments created by compensatory adjustments of the trunk and the resulting movement of the body center of mass.

Excessive anterior tilting of the pelvis resulting from weakness of the posterior rotators of the pelvis (ie, gluteus maximus, hamstrings, and abdominals) and/ or tightness of the hip flexors may result in a posterior shift in the trunk position, placing more stress on the knee joint. Given the fact that impaired trunk proprioception and deficits in trunk control have been shown to be predictors of knee injury, the development of “core” programs should consider dynamic pelvis stability as an important piece.

Dynamic Hip Joint Control

While there is some debate whether abnormal hip kinematics are the result of diminished hip muscle strength or impaired motor control, both aspects of muscle performance should be considered when implementing a rehabilitation or injury prevention program. In particular, the gluteus maximus and gluteus medius should be the targeted muscles due to their important roles in dynamic hip stability. The gluteus maximus is best suited to provide 3-dimensional stability of the hip, as this muscle resists the motions of hip flexion, adduction, and internal rotation and is a strong hip extensor and external rotator. In contrast, the gluteus medius mainly functions to stabilize the femur and pelvis in the frontal plane.

Summary and Physical Therapy First Implications

It can be argued that interventions which address proximal impairments including pelvis and trunk stability and dynamic hip control may be beneficial for patients who present with various knee conditions. The therapists at Physical Therapy First are proficient at evaluating the strength and dynamic control of the trunk and pelvis, and creating individualized treatment plans and home exercise programs to address proximal impairments which could be contributing to knee pain.

Reference:

Powers, Christopher (2010). The Influence of Abnormal Hip Mechanics on Knee Injury: A Biomechanical Perspective. Journal of Orthopedic and Sports Physical Therapy. Vol 40, Number 2, pages 42-51.

Barefoot Running: Biomechanics and Implications for Running Injuries

by | Aug 3, 2020 | Health Tips

By Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

Introduction

As a species, humans have evolved from running barefoot for survival. Footwear has also evolved over the past 10,000 years into modern-day cushioned running shoes. Despite the technological advances in running shoes, it is estimated that up to 80% of runners sustain a running-related injury (RRI) in a given year. This high incidence rate of injuries leads researchers to question whether our modern-day running shoes are contributing to RRIs and if humans should be running barefoot, like our ancestors. Researchers in the article, Barefoot Running: Biomechanics and Implications for Running Injuries, look at the biomechanics of barefoot running compared to minimalist shoes and modern-day running shoes and their implications on RRIs.

Running Mechanics in Modern-Day Running Shoes

The modern-day running shoe has a dual-density midsole, elevated cushioned heel, arch support, stiff heel counter, and an array of other features proposed to help foot function and reduce the likelihood of sustaining a RRI. When wearing these shoes, it is estimated that 75% of runners land on their heel or rearfoot strike (RFS), 24% land with foot-flat or mid-strike (MFS), and 1% land on the ball of their foot in a forefoot strike (FFS). Landing with a RFS causes high loading rates through the lower extremity while FFS has a reduced loading rate force at impact.

Running Injuries in Modern-Day Footwear

The majority of runners who wear modern-day shoes are RFS (75%). The authors reported mild and moderate RRIs occurred 2.5 times more frequently in RFS than in FFS.  Higher vertical loading rates at impact and abnormal mechanics are thought to contribute to injury risk. Vertical loading rates have been shown to be higher in RFS runners with a history of tibial stress fractures, patellofemoral pain syndrome (PFPS), and plantar fasciitis. The knee is the most common site of running injuries, followed by the lower leg, foot, and upper leg. PFPS, iliotibial band syndrome, tibial stress syndrome/fractures, plantar fasciitis, and Achilles tendinitis are typically among the most common injuries reported. There are also reported cases on anterior compartment syndrome due to hypertrophy of the anterior shin muscles in RFS runners.

Barefoot Running Mechanics

Barefoot running is associated with a FFS, shorter stride length, and higher cadence compared to modern-day footwear runners. Contrary to the belief that the medial longitudinal arch will fall in barefoot runners, studies show there is actually shortening of the arch over time in FFS runners. Hindfoot eversion, knee flexion, knee adduction, and hip external rotation moments were also reduced when running without shoes. With a FFS, there are greater loads through the posterior calf musculature as well as increased stress on the metatarsal heads. In addition, the act of being barefoot appears to allow for more sensory input to the neuromuscular system and static balance has shown to be better when standing barefoot compared to when wearing socks.

Barefoot/Minimalist Shoes

The authors reported on studies which looked at the striking pattern of runners wearing a minimalist shoe.  One study reported that runners actually landed in greater dorsiflexion and exhibited greater vertical load rates and tibial shock compared with a modern-day running shoe. Another study looked at a transition of 14 runners into a minimalist shoe. Of the 14 runners, 10 of them began the training program landing with an RFS pattern. After 6 weeks of training, all runners landed less dorsiflexed, but surprisingly, five of them still remained RFS runners. Without the sensory feedback between the sole of the foot and the surface of the ground, the runner may not have the complete neural cueing to convert to a FFS. Minimal footwear, like barefoot running, offers no foot support, thereby increasing the demand on the foot and ankle musculature. Another study following minimalist shoe runners showed a significant increase in the cross-sectional area of some of the intrinsic and extrinsic muscles of the foot and ankle, an indication of strengthening.

Barefoot/Minimal Footwear Running Injuries

The top reason that runners choose to switch to barefoot/minimal footwear is to avoid future injury. However, the most prevalent barrier to barefoot/minimal footwear running reported in the literature was fear of possible injury. In fact, there is little evidence that proves injury risk is increased in barefoot and minimal footwear running. There have been reported cases of metatarsal stress fracture in barefoot/minimal footwear runners and there is also an increased likelihood of calf strains and Achilles tendonitis due to the nature of FFS and increased loading in the posterior calf. It is true however that the foot is exposed when barefoot and thus more vulnerable to cuts, bruises, and abrasions.

Transitioning to a Minimalist Shoe

One of the biggest theoretical risk factors in barefoot running is doing too much, too quick, too soon. Habitual RFS runners wearing modern running shoes with 10 to 14 mm elevated, cushioned heels should not abruptly change their footwear to zero drop while maintaining their current mileage. It is imperative to follow a program that transitions runners slowly to the use of minimal footwear and the adoption of a mild FFS pattern. The most common problem associated with transition is soreness in the lower leg and foot. The authors conclude that while it appears that runners plagued with injury may benefit from switching to a barefoot strike, there is less justification for injury-free runners to change running mechanics. It is also unknown how barefoot running may affect those with special foot conditions, such as bunions, severe diabetes, or neuromas.

Future Research

There is currently a significant amount of knowledge that is not known about barefoot running. Future studies need to address differences between FFS in modern-day footwear vs barefoot running, who is appropriate for barefoot running, what are the best ways to transition to barefoot running to minimize injury risk, are there less injuries in barefoot runners vs. runners who wear modern-day shoes, and what are the long-term effects on bone and joint health. Well controlled, large-scale, prospective injury studies are needed to determine whether shedding our shoes while we run is truly good for our health.

Conclusions and Implications for Physical Therapy First

One could argue that running with heavily cushioned shoes is unnatural and may contribute to the high rate of injuries that runners experience today. Clearly there are well documented biomechanical differences between barefoot and RFS running. The injury risk associated with barefoot however running is largely unknown. At Physical Therapy First, our clinicians are trained to perform gait evaluations and will use this knowledge to offer footwear and training suggestions on a case-by-case basis. If you are a runner with frequent pain and/or want to improve your performance, you could benefit from an evaluation by one of our therapists to keep you training at your healthiest.

Reference:

Altman, A., Davis, I. (2012). Barefoot Running: Biomechanics and Implications for Running Injuries. American College of Sports Medicine. Vol. 11, Number 5 (244-250).

Factors Affecting Training And Physical Performance In Recreational Endurance Runners

by | Jul 28, 2020 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

INTRODUCTION

Recreational running is a simple and accessible sport attracting millions of participants world-wide. Despite the great popularity, there is no consensus on best training practices for improved performance. There are, however, a plethora of anecdotal guidelines without robust scientific support. The authors’ goal in the article, Factors Affecting Training and Physical Performance in Recreational Endurance Runners, is to present a selection of scientific evidence regarding the best training practices and provide a starting point for further studies. The study focuses on key aspects of training, such as periodization, training methods and monitoring, performance prediction, running technique, and prevention and management of injuries associated with endurance running. Below is the summary of the authors’ recommendations regarding various aspects of training.

Recommendations for Training Characteristics of Recreational Endurance Runners

Running Training Methods

  • A combination of methods, including one to two high-intensity interval training (HIIT) sessions per week plus more sessions with moderate- and low intensity continuous sub-maximal running, is generally recommended to improve performance in recreational runners in a healthy manner.

Strength Training (ST)

  • Although there is a lack of knowledge regarding the optimal volume and intensity of ST for endurance running performance, the inclusion of ST in the training regime of recreational runners might be recommended, even for marathoners.

Training Intensity Distribution

  • The pyramidal and polarized training models might be the most recommended forms of training intensity distribution for recreational runners, with different considerations depending on competitive distance, time available to train, and time of the season.
    • Pyramidal Training Model: Ramp distance and/or speed up and then back down in a “pyramid-like” style.
    • Polarized Training Model:  Focus on different running intensities (low or high intensity) at each training session.

Training Periodization

  • Periodization is the altering of frequency, intensity, and volume of training sessions over a period of time to help runners arrive at peak fitness on race day.
    • Linear Periodization: This training method uses four phases, comprised of a base phase, strength phase, anaerobic phase, and racing phase. This training method has proven successful for runners competing in short or moderate distances less than 21 Kilometers.
    • Reverse Linear Periodization: Opposite of linear periodization, this training method focuses on shorter, more intense workouts which gradually transition into longer, less intense workouts closer to race-day. This method is good for marathon training, novice runners, and for strength training.
    • Block Periodization: This method separates the volume and intensity elements of the training period, possibly in separate weeks. This training method has proven to be effective for short or moderate distance runners.

Training Monitoring

  • Monitoring is used by the coach and runner to maximize training performance. Incremental field-testing for identification of maximum aerobic speed (MAS) could be considered the most practical, as MAS integrates both VO2max and running economy (RE) into a single parameter. RE is the energetic cost of running at a given speed.

Performance Predictions

  • The best way to predict recreational runners’ racing times may be to record individual performances over shorter distances and to conduct assessments close to the race pace. For instance, complementing actual shorter distance training results with the expected steady state pace during the event could predict running performance.

Factors Associated with Running-Related Injuries

Running Technique (RT)

  • Contrary to common belief, the search for a “one-size-fits-all” RT is not accompanied by improvement in performance or RE. In this regard, the recommendation of a global RT is not effective nor advisable.
  • The strongest direct links with RE are running biomechanics during the contact phase, particularly those during propulsion or push-off. Thus, a protocol for increasing the preferred stride frequency by 10% while reducing the preferred stride length by 10% decreases the peak hip adduction angle and vertical loading rates; parameters associated with RRIs.
  • There is no evidence that forefoot strike vs. rearfoot strike is advantageous for improved running performance.

Risk Factors

  • The most important intrinsic risk factor for endurance running injury is the existence of a previous injury, indicating that special attention should be taken to avoid recurrent injuries in endurance runners. Using a gradual increase in training load in the first weeks of training after recovery is paramount.
  • A high weekly running mileage is another risk factor among recreational endurance runners. For this reason, training for long distance races (e.g., ultra-endurance competitions) is also a risk factor for incurring running-related injuries
  • If training is balanced according to the characteristics and experience of the athlete while avoiding both overuse and underconditioning, injury risk is expected to be controlled even in the case of conducting high volumes of training.

Running shoes

  • Current evidence does not support the claim that increased shock absorption reduces the likelihood of injury.

Diet

  • The available evidence is insufficient to determine whether total energy intake per day or macronutrient and micronutrient proportions in the diet are associated with the prevalence of injury in endurance runners.
  • The International Olympic Committee indicates that only two supplements are sufficiently supported by science: Vitamin D to treat nutrient deficiencies that can lead to bone injuries and creatine to maintain lean mass during periods of immobilization after injury.

Conclusions and Physical Therapy First Implications

Preparations should be made for long-distance events, such as marathons and ultra-endurance races, to balance conditioning without increasing the risk of overuse injuries. Runners with one or more risk factors for endurance running injuries should be aware of the first signs of injury and should immediately change their training practices or cease training to elude other risk factors. At Physical Therapy First, we keep these recommendations in mind and focus on prevention of injuries in addition to treatment of RRIs to keep you healthy for your next race.

Reference:

Boullosa, D., Esteve-Lanao, J., Casado, A., Peyre-Tartaruga, Leonardo., Gomes da Rosa, Rodrigo., Del Coso, Juan (2020). Factors Affecting Training and Physical Performance in Recreational Endurance Runners. MDPI Sports: 8, 35.

 

Analysis Of Running-Related Injuries: The Vienna Study

by | Jul 28, 2020 | Health Tips

by Sarah Voelkel Feierstein PT, DPT, OCS, CMPT

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.