The Injured Runner: An Evidence-Based Approach. Part One: Running Injuries

The Injured Runner:
An Evidence-Based Approach
Part One: Running Injuries

Allan Besselink, PT, Dip. MDT

Director,
Smart Sport International
Smart Life Institute
Austin, Texas

Background

Physical therapist (1988)
●

McKenzie Diploma (1998)
●

USA Track and Field
●

Endurance sports coach
●

(running, triathlon)
Educator (PT; PTA)
●

Author - “RunSmart: A
●

Comprehensive Approach To
Injury-Free Running” (2008)
2

Evidence

3

Evidence-Based Medicine

“The plural of anecdote is not data”
(Frank Kotsonis)

“In God we trust – all others bring data”
(Nik Bogduk)

4


“The conscientious, explicit, and judicious
use of current best evidence in making
decisions about the care of individual
patients.”
Sackett DL, Rosenberg WM, Gray JA, Haynes
RB, Richardson WS. Evidence based
medicine: What it is and what it isn't. Br Med
J, 1996; 312:71–72.

5


But, one problem exists -

Evidence is of no use if it is not integrated and
–
utilized in the assessment and treatment algorithm
Evidence must also extend to consumer awareness
–

6

Belief Systems

The impact of the provider's belief systems
may be greater than the evidence

Ross (1994):
“Our beliefs are the truth;
–

The truth is obvious;
–

Our beliefs are based on real data;
–

The data we select are the real data”
–

7

Belief Systems

8

Belief Systems

“The inability to challenge our belief systems
in the face of good scientific evidence is the
primary limiting factor in the advancement of
both health care and coaching, as well as
human performance and injury prevention”
(Besselink 2008)

9

Belief Systems

It is a very uncomfortable struggle to integrate
evidence into your thinking – especially if it is
contrary to your current beliefs

10

Thinking

“To arrive at a contradiction
is to confess an error in
one’s thinking; to maintain a
contradiction is to abdicate
one’s mind and to evict
oneself from the realm of
reality”
(Rand)

11

Evidence ...

… regardless of it's
impact on the
provider's bottom
line or their personal
beliefs

It is an issue of cost,
of efficacy, and of
autonomy.
12

Lessons Learned: Back Pain

What assessments?
●

What treatments?
●

Well-established clinical
●

guidelines

Use the lessons learned
from back pain research!

13

Evidence

14

A Brief History Of
Running Injuries
Perceived causes:

15

A Brief History Of
Running Injuries
Perceived causes:
Muscle imbalances
–

Lack of flexibility
–

Incorrect footwear
–

Leg length discrepancy
–

Foot structure
–

Too much speed work
–

Asymmetry and mal-alignment
–

16

A Brief History Of
Running Injuries

30+ years of scientific evidence would indicate:

No specific correlation between anatomic mal-
alignment or variations in the lower extremity
and any specific pathological entities or
predisposition to any “overuse syndromes”

17

A Brief History Of
Running Injuries
James SL, Bates BT, Osternig LR. Injuries to runners. Am
●

J Sports Med 1978; 6: 40-50.
Jacobs SJ, Berson BL. Injuries to runners: a study of
●

entrants to a 10,000 meter race. Am J Sports Med 1986;
14: 151-155
McQuade K. A case-control study of running injuries:
●

comparison of patterns of runners with and without running
injuries. JOSPT 1986; 8: 81.
Lysholm J, Wiklander J. Injuries in runners. Am J Sports
●

Med 1987; 15: 168-171.

18

“Normal”

“Malalignment is a
term that should be
reserved for gross
abnormalities, two
standard deviations
outside the norm”
(Reid 1992)

19

In the meantime ...

What do patients continue to hear from doctors,
chiropractors, and physical therapists treating
injured runners?
Muscle imbalances
●

Lack of flexibility
●

Incorrect footwear
●

Leg length discrepancy
●

Foot structure
●

Too much speed work
●

Asymmetry and mal-alignment
●

20

Evidence

21

MRI And Imaging

Perceived value of imaging in the assessment
process
Does the cost of imaging outweigh the
benefits?
Is imaging relevant and pertinent as a first line
of assessment?

22

MRI And Imaging

Krampla WW, Newrkla SP, Kroener AH, Hruby WF.
●

Changes on magnetic resonance tomography in the knee
joints of marathon runners: a 10-year longitudinal study.
Skeletal Radiol 2008; 37(7):619-26.
Stahl R, Luke A, Ma CB, Krug R, Steinbach L, Majumdar
●

S, Link TM. Prevalence of pathologic findings in
asymptomatic knees of marathon runners before and after
a competition in comparison with physically active
subjects-a 3.0 T magnetic resonance imaging study.
Skeletal Radiol 2008; 37(7):627-38.

23

MRI And Imaging

Schueller-Weidekamm C, Schueller G, Uffmann M, Bader
●

TR. Does marathon running cause acute lesions of the
knee? Evaluation with magnetic resonance imaging. Eur
Radiol 2006; 16(10): 2179-85.
Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi
●

M. 1995 Volvo Award in clinical sciences. The diagnostic
accuracy of magnetic resonance imaging, work perception,
and psychosocial factors in identifying symptomatic disc
herniations. Spine 1995; 20(24):2613-25.

24

MRI And Imaging

Guten GN, Kohn HS, Zoltan DJ. 'False positive' MRI of the
●

knee: a literature review study. WMJ 2002; 101(1):35-8.
Sein ML, Walton J, Linklater J, Harris C, Dugal T,
●

Appleyard R, Kirkbride B, Kuah D, Murrell GA. Reliability
of MRI assessment of supraspinatus tendinopathy. British
Journal of Sports Medicine 2007; 41(8).

25

MRI And Imaging

Lessons learned from back pain: 70% of
●

asymptomatics have a positive MRI
If a patient has a positive MRI, what does it tell
●

us?
Similar data exists for shoulders and knees
●

Well-established clinical guidelines would
●

indicate that this should not be a first line of
assessment

26

In the meantime ...

What will physicians and chiropractors have the
patient do as a first line of assessment?
MRI
–

Radiographs
–

CT scans
–

27

Evidence

28

Assessment Techniques

Perceived value in the clinical reasoning
process

Three primary approaches:
Palpation-based
–

Movement-based
–

Provocation-based
–

29

Palpation

Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson
●

VM, Murphy LS, Reinsch S. Reliability of spinal palpation
for diagnosis of back and neck pain: a systematic review of
the literature. Spine 2004; 29(19).
van Trijffel E, Anderegg Q, Bossuyt PM, Lucas C. Inter-
●

examiner reliability of passive assessment of intervertebral
motion in the cervical and lumbar spine: a systematic
review. Manual therapy 2005; 10(4): 256-269.

30

Asymmetry

Badii M, Shin S, Torreggiani WC, Jankovic B, Gustafson
●

P, Munk PL, and Esdaile JM. Pelvic bone asymmetry in
323 study participants receiving abdominal ct scans. Spine
2003; 28(12): 1335-1339.
Patients without back pain
–

82.7% asymmetrical; 5% > 5mm
–

previous reports of 24 – 91% (in back pain
–
patients)
Can this be palpated?
–

31

Sacroiliac Joint

Sturesson B, Selvik G, Udén A. Movements of the
●

sacroiliac joints. A roentgen stereophoto-grammetric
analysis. Spine 1989; 14(2): 162-5.
2.5 degrees of rotation, 0.7 mm of translation
–

No difference between asymptomatic and
–
symptomatic joints

32


Palpation-based assessment techniques are
●

inherently unreliable
What are the ramifications if two people can't
●

agree on what they feel – and do so
consistently?
If there is questionable inter-rater reliability,
●

then what is the level of validity?

33

Motion/Provocation

Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S,
●

Telje T. The reliability of selected motion- and pain
provocation tests for the sacroiliac joint. Manual Therapy
2007; 12(1): 72-79.
Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley
●

JH, Laslett M, Bogduk N. Systematic review of tests to
identify the disc, sij or facet joint as the source of low back
pain. European spine journal : official publication of the
European Spine Society, the European Spinal Deformity
Society, and the European Section of the Cervical Spine
Research Society 2007; 16(10): 1539-1550.

34

Repeated Movements

Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H.
●

Efficacy of flexion and extension treatments incorporating
braces for low-back pain patients with retrodisplacement,
spondylolisthesis, or normal sagittal translation. Spine
1993; 18(13): 1839-49.
Kilpikoski S, Airaksinen O, Kankaanpää M, Leminen P,
●

Videman T, Alen M. Interexaminer reliability of low back
pain assessment using the McKenzie method. Spine 2002;
15; 27(8): E207-14.

35

Centralization

Werneke MW, Hart DL, Resnik L, Stratford PW, Reyes A.
●

Centralization: prevalence and effect on treatment
outcomes using a standardized operational definition and
measurement method. J Orthop Sports Phys Ther 2008;
38(3):116-25.
Skytte L, May S, Petersen P. Centralization: its prognostic
●

value in patients with referred symptoms and sciatica.
Spine 2005; 30(11): E293-9.
Aina A, May S, Clare H. The centralization phenomenon of
●

spinal symptoms--a systematic review. Man Ther 2004;
9(3): 134-43.

36


Movement-based and provocation-based
assessment techniques – reliability and validity

Centralization as a prognostic indicator

Repeated movement testing as reliable as MRI
but with far less cost!

37

In the meantime …

What do doctors, chiropractors, massage
therapists, and physical therapists continue to
utilize as a primary form of assessment and
upon which they base their clinical reasoning?
Palpation-based assessment techniques
–

38

Evidence

39

Treatment Interventions

Perceived Causes:
Muscle imbalances
●

● Lack of flexibility

● Incorrect footwear

● Leg length discrepancy

● Foot structure

● Too much speed work

● Asymmetry and mal-alignment

40


Treatment Interventions:
Modalities
●

● Active Release Therapy/Graston

● Strain-Counterstrain

● SI joint manipulation

41


Treatment Interventions:
Orthotics and heel lifts
●

● Shoes

● Core stabilization

● Stretching

● Aquajogging

42


Systematic reviews
Modalities (ultrasound, electrical stimulation)
–

Spinal manipulation
–

ART/Graston
–

Orthotics
–

Stretching
–

Core stabilization
–

43


Based on the scientific literature regarding
treatment interventions, what do chiropractors,
massage therapists, and physical therapists
continue to utilize?

44

Community Standards

Accepted Community Standards Of Care
(what providers and patients consider “acceptable”)
vs
Evidence-Based Standards Of Care
(clinical guidelines; outcomes-driven)

45

Problem

ACSC and EBSC are not the same!

ACSC has unfortunately become “gold
standard” with patients

46

Responsibility

We continue to tell payors that evidence and
outcomes are important …

We continue to tell legislators that evidence and

We continue to tell students that evidence and
47

Responsibility

We continue to tell patients that evidence and

Our professional association continues to
advocate it ...

48

But In The Words Of Gandhi ...

“We must be the change
we wish to see in the
world”

49

Challenge Your Thinking!

“We can't solve
problems by using the
same kind of thinking
we used when we
created them.”
(Einstein)

50

For More Information:

Smart Sport International
●

www.smartsport.info
Smart Life Institute
●

www.smartlifeinstitute.com
“Consumer's Guide To Health”
●

Every second Tues at 8:00pm CT
www.blogtalkradio.com/abesselink
“RunSmart: A Comprehensive Approach To
●

Injury-Free Running”
www.lulu.com/abesselink
51

Photo Credits
All photos Creative Commons (Attribution-No Derivative)
#3, 14, 21, 28, 39, 94 “Evidence” on Flickr by billaday
–

#8 “Counterstatement to what sean calls 'evidence'” on Flickr by astera
–
snowwhite
#12 “Choose your evidence carefully” on Flickr by rocket ship
–

#49 “Il y a 60 ans, Gandhi assassinéquot; on Flickr by ah zut
–

#13, 51: Allan Besselink
–

All others understood to be public domain/fair use and all attempts have
–
been made to identify all image owners and licenses

52

The Injured Runner: An Evidence-Based Approach. Part One: Running Injuries

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The Injured Runner: An Evidence-Based Approach. Part One: Running Injuries