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

Keys to the Office Based Evaluation of the Youth Runner

12/15/2018

Michelle Cappello, PT, SCS Clinical Director of Physical Therapy and Athletic Training Sports Medicine Center for Young Athletes UCSF Benioff Children’s Hospitals

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

Disclosure

 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.

Learning Outcomes

Cardiovascular fitness (e.g. running ability), but not muscle strength, is strongly associated with higher cognitive performances.

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.

Fact For Thought

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.

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.

Fact For Thought

Keys to Office Exam of the Youth Runner 6

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

Material Fatigue

Demands > Durability

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Tissue Overuse & Injury: Envelope of Function

Dye, Clin Orthop Rel Res, 1996

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Taunton et al., Br. J Sports Med, 2002

• 1. Knee (42%)
• 2. Foot/ankle (17%)
• 3. Lower leg (13%)
• 4. Hip/pelvis (11%)
• 5. Achilles/calf (7%)
• 6. Upper leg (5%)
• 7. Low back (3%)
• 8. Other (2%)

Most common sites of injury in runners 10 most common overuse injuries in runners

• 1. Patellofemoral pain (21%)
• 2. ITB friction syndrome (11%)
• 3. Plantar fasciitis (10%)
• 4. Meniscal injuries (6%)
• 5. Shin splints (6%)
• 6. Patellar tendinitis (6%)
• 7. Achilles tendinitis(6%)
• 8. Gluteus Medius injuries (4%)
• 9. Tibia stress fractures (4%)
• 10. Spine injuries (3%)

Physical Assessment

• Posture
• Range of Motion
• Stability / Control
• Balance
• Strength / Power

Najee Davis: UCSF BCHO Athlete of the Month April 2013

Motion Analysis Synthesis of Information Plan of Action Office Based Evaluation of the Youth Runner

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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,

• verlapping 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.

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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

Neutral

• Runners should hip hinge 10-

15 degrees = Forward Trunk Lean, less PF Stress

• Straight line from cervical

spine to sacrum

Teng & Powers JOSPT 2014 13

Physical Assessment: Functional Testing Posture

Poor Trunk Control in Sitting Poor postural endurance -> flexed runner

Physical Assessment: Functional Testing Posture

• Decreased

lumbar lordosis / posterior pelvic tilt

• Increased

thoracic kyphosis

• Deactivates

gluteals

• Increased

demand on quads

• Decreased hip

hinge

 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

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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

Linking UE & LE

Physical Assessment: Functional Testing Posture

Presentation Title 19

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°

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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

Physical Assessment: STABILITY Core

Presentation Title 22

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

Presentation Title 23

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

Presentation Title 24

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

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Physical Assessment: STABILITY Functional Testing

Single Limb Squat

• Highlights dynamic tracking
• f Hip/pelvis in the frontal

and rotational planes

• 3-5 practice reps
• Goal for running 3 x 20 if can

do well

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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.

Physical Assessment: STRENGTH

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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”

• Should be able to

maintain full hip extension

• Minimum of 15 reps

Photo credit to C.Deprato UCSF PT

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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

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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

• n way down.

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Physical Assessment: Functional Testing POWER

Strength: Propulsion Power

• Broad Jump (Double leg)

Distance should be own height

• Single leg Broad Jump = >90%
• Look for LSI >90% R vs. L

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Physical Assessment: Functional Testing

Motion Analysis Running

• Depending on symptoms, Goal is to see how they run
• Objectively measures what body is doing
• Look for inefficiencies and injury inducing mechanics

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Physical Assessment: Functional Testing

Motion Analysis Running

• Video Analysis on phone or office iPad

 check posterior view

• pelvic drop
• knee window (no “knocked knees)

 check anterior view

• medial knee collapse in stance leg
• trunk side lean in/towards stance leg

 check side view

• Trunk lean 10° & postural alignment
• hip extension 10°
• Can they get their leg behind them
• Landing close to their body

Posture Exam – holds neutral spine with arms overhead x10 Mobility – Hip extension >10 degrees Mobility – Great toe extension >30 degrees Stability – Plank holds front/side 30 seconds Stability – Single Leg balance 30 seconds Stability – Single Leg Squat x 10 with good mechanics Strength – Double Leg Squat with good hip strategy x 10 Strength – Bridge Test – double & single leg Strength – Runner’s Lean Single leg calf raise x 20 each side Power - Broad Jump (double leg) distance = patient’s height Power - Broad Hop (single leg) 70-90% of height Walking Test: 10 minutes at fastest speed (just short of jogging). No pain or limping. Step and Hold: 20 small leap steps from the one limb to the other limb. Step should be at least the distance

• f the patient’s normal stride length with gait.

Keys to the Office Based Evaluation of the Youth Runner

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Keys to Office Exam of the Youth Runner

Review of Findings

• List Physical Assessment & Run analysis

findings:

• Establish a Plan of Care
• Mobility deficits = stretch & mobilize target

areas

• Stability deficits – control and coordination

in patterns

• Strength/power – isolate weak muscles,

then build power with patterns of movement

• Mechanics – gait retraining with movement

rehabilitation specialist

• Neither – will focus more on shoes,

volumes/demands, and medical considerations

Thank You!

Michelle Cappello, PT, SCS

Clinical Director Sports Medicine Center for Young Athletes

mcappello@mail.cho.org