Mixed method study with Running Re-Training

[Laura Thornton]

If you guys didn’t see this already, BJSM published a new article on a mixed systematic review and expert interviews on running re-training. They compile all the current evidence on retraining, then ask 16 experts different questions on different strategies, conditions, barriers, prevention, etc.

Some interesting components:

Experts compare the different diagnoses for which they would change rearfoot >> forefoot strike pattern vs. forefoot strike pattern >> rearfoot.

Increasing step rate seems to be supported for a multitude of different conditions and for changing different joint loading moments, but inconsistent thoughts for hamstring injuries.

I think anecdoctal and expert opinions are huge, and to combine both in this paper is fantastic. I wanted to share an evaluation I did today that this paper already helped with, and get your feedback if anyone has seen similar patients!

16 yo female freshman in high school. Plays soccer (spring and club) and runs cross country (fall) and track (winter) for school. Currently in soccer season, 2 weeks left of competitive season. Is planning on club soccer and training for cross country season this fall (3-7 miles, several times a week).

Chief complaint: Pain in left posterior lower leg (proximal calf). Describes as sharp pain, tenderness to palpation, and “pulling/tightness”. Denies pain into distal lower leg, foot, thigh, or hip. Denies numbness or tingling. Aggravating factors: Walking and Running. Walking – immediate onset, but will be minimal pain until 5-10 minutes will start to increase. Will continue to be painful until seated rest. Running – immediate onset, will feel minimal pain during running but will be worse after the run, will continue until seated rest. With both running and walking, pain will diminish within 10 seconds of seated rest break. Eases: seated rest, ice.

MOI: Last Friday, was playing in soccer game (second half) and felt sharp pain and cramp in left lower leg, had to leave game. Felt “knotted up” and calf starting shaking/quivering. Was like that for the end of the night, then felt less pain in the morning, although started hurting worse through the rest of the day. Has eased since Saturday, but is still bothersome with current activities listed above. Saw MD on Tuesday, diagnosed with calf strain.

HPI: First episode of bilateral calf sprains happened in August. She was participating in cross-country and club soccer. It was about a month into both sports, and started experiencing calf pain (larger area than current area, was entire calf muscle vs. just proximal). She went through extensive testing. Bone scan, negative in lower leg but in hips, they found “hot spots” that were benign. Then started physical therapy for 3 months – strengthening hips, glutes, and quads. Stretches for the hips. Made the calf hurt at first, but eventually it made it stronger for February (start of soccer season). It was feeling a lot better, and were able to run with no pain. She has not been doing the exercises since the season started.

PMH: osgood schlatter, plantar fasciitis B (2-3 years ago)

Primary Hypothesis: L calf strain
Differential Diagnosis:
– Posterior tibialis tendinopathy
– Popliteal artery entrapment syndrome
– Exertional compartment syndrome
– DVT

Objective: In standing, left patella rests in externally rotated and inferior position compared to the right. Slight hip internal rotation on the left compared to the right. Neutral calcaneal position in standing, does not sit in eversion or inversion bilaterally. No hypertrophy, no discoloration, no swelling, no observable changes. In prone, calcaneous rests in 7 degrees of inversion on R, 4 degrees of inversion on L.

SL stance: mildly increased ankle sway on the left with eyes closed compared to left

Gait (walk): at heel strike to loading response, internal rotation and genu valgus on the left compared with the right. Internal rotation maintained throughout stance phase. Decreased hip extension bilaterally. Greater shoulder extension on the left (wing greater on left). Does not excessively pronate.

Gait (run): increased hip internal rotation at heel strike on L. Strikes at forefoot B. Limited hip extension and increased dorsiflexion at push off bilaterally. Does not excessively pronate.

Swing test: limited hip extension bilaterally, moderate ankle sway on the left.

Single leg squat: genu valgus and increased hip IR/adduction bilaterally.
Heel raises: Can perform 20 heel raises bilaterally, but fatigues quicker on left.

ROM:
Dorsiflexion: 13 on R with knee straight, 21 with knee bent; 8 on L with knee straight, 18 with knee bent
Plantarflexion: 59 on R, 50 on L
Inversion: 24 on R, 21 on L with slight pain in calf
Eversion: 14 on R, 11 on L
1st MTP Extension: 70 on R, 61 on L
Hip Extension: Limited to 0 degrees bilaterally
Hip Internal rotation: 60 degrees on R, 55 on L
Hip External rotation: 45 on R, 30 on L
Hip flexion: Limited to 110 degrees bilaterally
Other testing:
Tenderness to palpation in proximal gastrocnemius musculature, lateral and medial muscle bellies.
Tightness in hip flexors, quad, and IT band bilaterally
Weakness in hip abduction, extension B (4/5)

Severity: Minimal to moderate (based on level of activity that reproduces pain, overall improving steadily since onset)
Irritability: Minimal (eases immediately upon rest, did not reproduce with running 5 minutes on treadmill during exam)
Stage: Acute on Chronic
Do the Features Fit: Yes – proximal calf strain

1. Would you all add anything else on the differential diagnosis list? How would you have ruled out popliteal artery or compartment syndrome?
2. Plan – increase hip ROM into extension and external rotation, increase functional hip strength and proximal stability, increase glute activation and control into terminal extension.
3. Videotape feedback for running analysis was really helpful for her – it definitely helped sink it why treating her hip was so important and why it was causing the issues lower
4. I’m debating on how much I want to change her stride pattern. I don’t see forefoot strikers commonly. My thoughts are that if we address the ROM and strength deficits, the force in her gastroc-soleus complex will decrease and we won’t have to change so much about her pattern. There’s some support in this article for increasing step rate for calf pain. Have you guys had success with any retraining for calf pain in the past?

I have video of her running. I can see if she’ll let me send to to you guys if anyone’s interested.

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[Nick Law]

Laura,

Thanks so much for posting this! Eric referenced it in his running medicine talk and in the talk last weekend – its truly a great article and definitely one to keep easily accessible.

I sure would go down the route you are – proximal extension strengthening to reduce need for distal propulsive force generation.

As Eric tried to point out, looking for things that jump out and correcting those will probably make a bigger difference than getting nit picky. In that line of thinking, if she is in 20 degrees of plantar flexion at initial contact, I probably WOULD look to change foot strike pattern. If forefoot contacts first but ankle is relatively neutral, then I wouldn’t change it. Same idea with step rate. Below 165 and I would definitely make it an issue, above 170 and I probably wouldn’t mess with it.

Would love to see the video if you can share it!

[Laura Thornton]

Thanks for your input Nick! Appreciate it. I’m glad to hear that you agree with my game plan. I’ve seen her twice since the initial onset and it’s interesting how quickly she fatigues with any single leg stance exercise, especially on the RIGHT. She played last Friday and had another mild calf sprain (but on the right) during the game, but again I think we are on the right track and hopefully will begin to see some differences in her function.

I see what you’re saying about relative plantarflexion and tibial position at initial contact. Good point – she’s relatively upright at initial contact but it’s at terminal stance/push off where she has excessive dorsiflexion.

The only other noticeable thing with her running analysis was her increased external rotation of her left foot in initial swing, also known as “medial heel whip”. It’s pronounced on the left side compared to the right. But I think you’re right, it might be getting to nit picky to change too many things off the bat. We’ll focus on our current game plan with ROM, control, and power at the hip at terminal extension and then make adjustments if we need later.

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