Youth Runner Michelle Cappello, PT, SCS Clinical Director of - PowerPoint PPT Presentation

Keys to the Office Based Evaluation of the Youth Runner Michelle Cappello, PT, SCS Clinical Director of Physical Therapy and Athletic Training Sports Medicine Center for Young Athletes UCSF Benioff Children’s Hospitals 12/15/2018

Disclosure The CME Committee reviewed the commercial interest and nature of the financial relationship that was disclosed and determined there was no relevant financial relationship with a commercial interest

Learning Outcomes  Describe basic biomechanical demands required for running  Describe normal interaction of the hip, knee, ankle, and foot during functional movements specific to the run cycle.  Describe clinical exams for range of motion, stability, and functional tasks related to running.  Plan appropriate treatment interventions based on clinical exam findings .

Cardiovascular fitness (e.g. running ability), but not muscle strength, is strongly associated with higher cognitive performances. Fact For Thought Aberg MA, Pedersen NL, Torén K, et al. Cardiovascular fitness is associated with cognition in young adulthood. Proc Natl Acad Sci U S A . 2009 Dec 8;106(49):20906-11.

A study of 1.44 million people shows being physical active (e.g. running) is associated with an average 20% lower risk of 13 types of cancer. Fact For Thought Moore SC, et al. Leisure-time physical activity and risk of 26 types of cancer in 1.44 million adults. JAMA Internal Medicine . May 16, 2016.

Running Basics • Humans were born to run! • Running is a common denominator in youth sports • Sports participation requires running, but fails to train how to run • 80% of running related injury related to overuse (material fatigue) Van der Worp et al, 2015, PLOS • Avoiding fatigue is easy • Run really slow • Land really close to your body • Land really soft • Downside = nowhere quickly 6 Keys to Office Exam of the Youth Runner

Material Fatigue Demands > Durability

Tissue Overuse & Injury: Envelope of Function Dye, Clin Orthop Rel Res, 1996 8

Most common 10 most common overuse sites of injuries in runners injury in runners 1. Patellofemoral pain (21%) 2. ITB friction syndrome (11%) 1. Knee (42%) 3. Plantar fasciitis (10%) 2. Foot/ankle (17%) 4. Meniscal injuries (6%) 3. Lower leg (13%) 5. Shin splints (6%) 4. Hip/pelvis (11%) 6. Patellar tendinitis (6%) 5. Achilles/calf (7%) 7. Achilles tendinitis(6%) 6. Upper leg (5%) 8. Gluteus Medius injuries (4%) 7. Low back (3%) 9. Tibia stress fractures (4%) 8. Other (2%) 10. Spine injuries (3%) Taunton et al., Br. J Sports Med, 9 2002

Office Based Evaluation of the Youth Runner Physical Assessment • Posture Range of Motion • • Stability / Control • Balance • Strength / Power Motion Analysis Synthesis of Information Plan of Action Najee Davis: UCSF BCHO Athlete of the Month April 2013

Start with History  Where is pain  What causes pain  Any previous injury  How often do you run – Miles per week  Recent changes; surface, shoes, volumes, overlapping seasons  Other exercises  Goals – most patients don’t want to run slow; Performance over injury prevention – if they want speed, they need to earn it. 11

Physical Assessment • Physical Assessment evaluates functional movement patterns specific to the components of running • Shock Absorption • Balance • Propulsion / Power Evaluate the functional pattern then break it down • - MOBILITY = enough range for optimal biomechanical patterns - STABILITY = true dynamic stability to not collapse under load - STRENGTH = power to propel body up against gravity • Special Tests as necessary based on symptoms and limitations 12

Physical Assessment: Functional Testing Posture Neutral • Runners should hip hinge 10- 15 degrees = Forward Trunk Lean, less PF Stress Teng & Powers JOSPT 2014 • Straight line from cervical spine to sacrum 13

Physical Assessment: Functional Testing Posture Poor postural endurance -> flexed Poor Trunk Control runner in Sitting • Decreased lumbar lordosis / posterior pelvic tilt • Increased thoracic kyphosis • Deactivates gluteals • Increased demand on quads • Decreased hip hinge

Physical Assessment: Functional Testing Posture  Head and Trunk Control in Sitting Upright runner

Physical Assessment: Functional Testing Posture Postural Test for Core Control Prolonged sitting can put undue stress and pressure on a child’s musculoskeletal system & forms bad habits Triggering: • Postural endurance limits • shortening of the hip and knee flexor muscles Correct with “Crown to Ceiling” a few times/hour http://www.hilaryking.net

Physical Assessment: Functional Testing Posture Overhead Reach Test with Core Control • Indication of upright trunk and postural control • Runner places back and head flat against wall • Try to touch thumbs overhead keeping elbows straight & back flat against wall Evaluate in standing, then in supine to • check PROM vs. AROM, x 10 reps. • Limitations due to • UE mobility deficit • Thoracic spine stiff into extension • Spinal stability dysfunction • Scapular stability dysfunction 17

Physical Assessment: Functional Testing Posture Linking UE & LE

Physical Assessment: MOBILITY Range of Motion Needed for Running • Hip Extension 10°minimum • Hip: achieve both passive and active hip extension or will increase demands at the knee and ankle • Knee: 0°- 145° • 20-50° at contact loading • 0° Propulsion push off • Full flexion for mid-swing (speed) • Foot/Ankle: • DF 10°with knee extended 30°with knee flexed • Big Toe Extension = 30° 19 Presentation Title

Physical Assessment: STABILITY Stability of Core: Planks • Front AND Side Planks Should be able to maintain full hip • extension and abduction • Test each side for symmetry • 30 seconds is the goal for holds • Important for trunk posture during stance limb to control shock / impact 20

Physical Assessment: STABILITY Core

Physical Assessment: STABILILTY Functional Testing Single Limb Balance • Assess total body load acceptance • Keeps the body in proper postural alignment • Minimum of 10 seconds Elite = >25 seconds • • Limb Symmetry Index of >90% is desired • * Trunk lean compensation • * Hip drop dysfunction 22 Presentation Title

Physical Assessment: STABILITY Functional Testing Single Limb Squat Assess shock absorption pattern • • Specificity of braking, stability, and propulsion for muscle actions • Mimics unilateral stance phase of running gait pattern, abductor strength and control (Earl 2007) • 65 degrees is reviewed as normal achievement with good mechanics and no pain (Kivlan 2012) • Running requires control of 20-50 degrees of knee flexion for impact stability 23 Presentation Title

Physical Assessment: STABILITY Functional Testing Single Limb Squat • Poor Single leg squat associated with posterior chain weakness which is underdeveloped in pre/adolescents (Wilk PMR 2016) Patterns are weak, note quality of squat • • PFPS individuals have greater ipsilateral trunk lean, contralateral pelvic drop, and knee abduction (Nakagawa 2012) • Limb Symmetry Index of >90% is desired with Y Balance Anterior Reach Test • Measure distance other leg can reach forward from toe of stance leg 24 Presentation Title

Physical Assessment: STABILITY Functional Testing Single Limb Squat Highlights dynamic tracking • of Hip/pelvis in the frontal and rotational planes • 3-5 practice reps • Goal for running 3 x 20 if can do well 25

Physical Assessment: STRENGTH Choose the right target areas • Hip strategy! For acceleration (Pandy • 2010), runners need gluteus maximus, gluteus medius, vasti, soleus, and gastrocs Bilateral Squat Dynamic valgus /symmetry =poor movement strategy • Early heel rise? =*tight heel chords • Knee forward quad dominant strategy leads to over‐stride. Hips back = good glut recruitment, contact close to COM. 26

Physical Assessment: STRENGTH

Physical Assessment: STRENGTH Strength / Control Gluteals Full hip extension allows • for power with propulsion – hip drive from initial stance – mid stance • Functional Leg lift test Functional Bridge “Hip • Drive” Photo credit to C.Deprato UCSF PT Should be able to • maintain full hip extension • Minimum of 15 reps 28

Physical Assessment: STRENGTH Bridge Test • Double leg, then try single leg for 15 repetitions • Essential for stance limb stability & propulsion Should be able to maintain full hip • extension • Preserve stable spine Positive test = default to • hamstrings, hamstring cramp, contralateral pelvis drops 29

Physical Assessment: STRENGTH Runner’s Calf Raise • Double leg to get full height of heel lift, then test is singles • Essential for stance propulsion Should be able to perform 20 • single heel lifts at full height • Foot to remain facing forward, no toe in or toe out bias • Positive test = lack of full height, foot turn out, excessive pronation on way down. 30