Orthopaedic Surgery - Running Injuries, Shod and Barefoot

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Basics

Running can be performed with:

Conventional running shoes

Minimalist footwear

or

Bare feet.

Modern conventional running shoes often incorporate:

Heel cushioning

Arch support

A relatively large heel-to-toe drop

and other features intended to influence comfort and load distribution.

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Barefoot and Minimalist Running

Barefoot or minimalist running has become an alternative to conventional footwear.

Advocates suggest that barefoot running may encourage:

Forefoot strike

or

Midfoot strike

rather than a predominant:

Rearfoot or heel strike.

They also propose that reduced footwear may improve:

Ground sensation

Proprioception

and movement patterns perceived as more natural.

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Concerns About Barefoot Running

Barefoot or minimalist running does not eliminate injury risk.

Potential concerns include:

Metatarsal stress injury

Skin injury

Puncture wounds

and overload of structures that may not be conditioned for the altered running pattern.

A rapid transition from conventional shoes to barefoot or minimalist running may be particularly problematic.

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Epidemiology

Running is a highly prevalent recreational and competitive activity.

Historical estimates suggest that more than:

25 million people in the United States

run on at least approximately:

50 days per year.

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Incidence of Running Injuries

Running-related injuries are common.

Older estimates suggest that as many as:

75% of runners

may experience an injury during a given year, depending on the population and definition of injury.

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Common Running Injuries

Frequently encountered disorders include:

Patellofemoral pain syndrome

Iliotibial band syndrome

Plantar fasciitis

Achilles tendinopathy

Patellar tendinopathy

Stress fractures

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Risk Factors

Running injury risk depends on multiple factors, including:

Training volume

Training intensity

Surface

Footwear

Running mechanics

Muscle strength

Flexibility

Previous injury

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Barefoot Running Risks

Barefoot running may increase the risk of:

Metatarsal stress fractures

and

Puncture wounds

particularly during abrupt transition or on unsafe surfaces.

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Shod Running Risks

Conventional running footwear has historically been associated with certain injury patterns, including:

Patellofemoral pain

and

Plantar heel pain

although footwear alone does not determine whether these injuries occur.

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Etiology

Most running injuries represent:

Overuse injuries.

They develop when repetitive loading exceeds the capacity of:

Bone

Tendon

Muscle

Fascia

or

Joint structures

to recover and adapt.

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Training Load

A major contributor is:

Excessive or rapidly increased training volume.

Sudden changes in:

Mileage

Speed

Hills

Running surface

or

Footwear

may increase tissue loading beyond the athlete’s current capacity.

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Impact Forces

Injury risk may also be influenced by:

Peak impact force

and

Loading rate.

The magnitude and distribution of these forces vary according to:

Foot-strike pattern

and

Footwear.

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Forefoot Versus Heel Strike

Barefoot runners often adopt a:

Midfoot or forefoot strike

which tends to redistribute loads away from the heel.

Conventional footwear may facilitate:

Rearfoot striking

in some runners.

Neither pattern is universally protective because each shifts stress to different structures.

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Forefoot Strike Loading

Forefoot striking may increase loading of the:

Calf musculature

Achilles tendon

Metatarsals

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Heel Strike Loading

Rearfoot striking may increase impact transmission through:

The heel

Knee

and other proximal structures depending on running mechanics.

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Patellofemoral Pain Syndrome

Patellofemoral pain is associated with increased stress between the:

Patella

and

Femoral trochlea.

Contributing factors may include:

Lower-extremity malalignment

Hip abductor weakness

Dynamic knee valgus

Quadriceps dysfunction

Training overload

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Plantar Fasciitis

Plantar fasciitis results from repetitive overload of the:

Plantar fascia

near its calcaneal origin.

Excessive:

Foot pronation or eversion

may contribute in some runners by increasing tensile loading of the fascia.

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Diagnosis

Most running-related overuse injuries are diagnosed primarily from:

History

and

Physical examination.

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Signs and Symptoms

The typical presentation is:

Activity-related pain

that worsens with running and improves with:

Rest

or reduction in training load.

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History

Important historical factors include:

Recent mileage increase

Change in running speed

New footwear

Transition to barefoot or minimalist running

Change in running surface

Hill training

Previous injury

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Examination

The examination should be directed toward the suspected injury and may include assessment of:

Gait

Lower-extremity alignment

Hip strength

Knee mechanics

Ankle motion

Foot posture

Tenderness

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Patellofemoral Assessment

Patellofemoral pain is suggested by:

Anterior or peripatellar pain

that worsens with:

Running

Squatting

Stairs

Prolonged sitting

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Patellar Grind Test

A historically described maneuver is the:

Patellar grind test.

With the patient supine and the knee extended, the examiner applies pressure to the patella while the patient contracts the:

Quadriceps.

Reproduction of pain has traditionally been considered positive, although the test has limited specificity and should not be interpreted alone.

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Iliotibial Band Assessment

Iliotibial band syndrome typically causes:

Lateral knee pain

during running.

The:

Ober test

may be used to assess iliotibial band or lateral hip tightness.

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Ober Test

The patient lies on the:

Contralateral side

with the symptomatic side upward.

The examiner:

Abducts and extends the hip

then allows the leg to lower toward adduction.

Restricted adduction may indicate:

Iliotibial band tightness.

Pain at the lateral knee may support the diagnosis in the appropriate clinical setting.

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Stress Fracture Assessment

Localized:

Bony tenderness

Pain with impact

Pain that progresses with continued running

should raise concern for:

Stress injury or stress fracture.

Pain occurring during daily activity or at rest suggests a more advanced injury.

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Imaging

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Plain Radiographs

Initial imaging for suspected bone or joint injury commonly includes:

Orthogonal radiographs.

Early stress fractures may have:

Normal radiographs.

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Later Stress-Fracture Findings

More established stress fractures may demonstrate:

Linear lucency

Cortical thickening

Periosteal reaction

Sclerosis

depending on the bone and chronicity.

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MRI

MRI is useful when:

Stress fracture is suspected despite normal radiographs

or when the diagnosis remains unclear.

It can identify:

Bone marrow edema

Stress reaction

Fracture line

and many:

Soft-tissue injuries.

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Treatment

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General Principles

The mainstays of treatment for most running-related overuse injuries are:

Activity modification

and

Rehabilitation.

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Training Modification

The most important intervention is often:

Reduction of training load.

This may involve temporary reduction in:

Mileage

Intensity

Hills

or

Impact activity.

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Relative Rest

Complete inactivity is not always necessary.

Cross-training using lower-impact activities may be appropriate when it does not reproduce symptoms.

Examples include:

Cycling

Swimming

Pool running

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Footwear Transition

Runners changing to minimalist or barefoot running should transition:

Gradually.

A sudden change in:

Foot-strike pattern

or

Tissue loading

can increase the risk of stress injury.

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Physical Therapy

Physical therapy may include:

Static stretching

Dynamic mobility exercises

Strengthening

Movement retraining

Gait assessment

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Core and Hip Strength

Particular emphasis is often placed on:

Core musculature

Hip abductors

Hip external rotators

because weakness in these areas may contribute to abnormal lower-extremity mechanics.

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Quadriceps Strengthening

Quadriceps rehabilitation may be useful for:

Patellofemoral pain

with attention to overall quadriceps function rather than isolated strengthening of only the:

Vastus medialis obliquus.

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Bracing and Orthoses

Selected patients may benefit from:

Bracing

Taping

or

Foot orthoses

depending on the specific diagnosis and biomechanics.

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Medication

Pain may be treated with:

NSAIDs

or

Acetaminophen

when appropriate.

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Ice

Post-activity icing may provide:

Short-term symptomatic relief.

It does not correct the underlying loading problem.

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Surgery

Most running overuse injuries do:

Not require surgery.

Operative treatment is reserved primarily for selected:

High-risk stress fractures

or structural injuries that fail appropriate conservative management.

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Tibial Stress Fracture

An anterior tibial cortex stress fracture may demonstrate the classic:

Dreaded black line.

This represents a high-risk:

Tension-side stress fracture

with a greater risk of:

Delayed union

Nonunion

or progression.

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Tibial Surgical Treatment

High-risk anterior tibial stress fractures may require:

Intramedullary nailing

or another stabilization procedure, particularly when persistent or progressing.

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Femoral Neck Stress Fracture

Femoral neck stress fractures are classified according to whether they involve the:

Compression side

or

Tension side.

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Tension-Side Femoral Neck Fracture

Tension-side fractures carry a relatively high risk of:

Displacement

and are generally treated with:

Surgical fixation.

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Compression-Side Femoral Neck Fracture

Compression-side fractures may be managed nonoperatively when:

Incomplete and stable.

Surgical fixation is generally considered when the fracture extends across approximately:

50% or more of the femoral neck width

or demonstrates other high-risk features.

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Fixation

Operative treatment commonly uses:

Percutaneous cannulated screws

or other appropriate fixation depending on fracture configuration.

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Follow-Up

Patients should be followed until:

Symptoms resolve

and normal function progressively returns.

Return to running should be:

Gradual

and based on symptoms and tissue healing rather than solely on elapsed time.

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Return to Running

A safe return generally requires:

Pain-free walking

Minimal or no tenderness

Restored strength

Adequate flexibility

Tolerance of progressive impact loading

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Prognosis

Most running-related overuse injuries have a:

Good prognosis

with appropriate modification of training and rehabilitation.

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Recurrence

Recurrence is relatively common when runners resume:

High training volumes

or increase loading:

Too quickly.

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Complications

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Stress-Fracture Progression

An untreated stress reaction may progress to a:

Complete fracture.

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Nonunion and Malunion

High-risk stress fractures may develop:

Delayed union

Nonunion

or

Malunion.

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Femoral Neck Complications

A displaced femoral neck stress fracture may compromise the blood supply to the femoral head and cause:

Avascular necrosis.

This is one of the most serious complications of running-related stress injury.

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Patient Monitoring

Patients should be monitored until:

Pain has resolved

Strength and flexibility are restored

Running mechanics are acceptable

and a graded return to activity can be completed without recurrence.

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Key Principle

Most running injuries are overuse disorders caused by an imbalance between repetitive training load and the ability of bone, tendon, muscle, or fascia to adapt.

Barefoot and conventional running redistribute loads differently rather than making running uniformly safer or more hazardous.

Barefoot or forefoot-strike running may increase stress on the:

Metatarsals and Achilles-calf complex, whereas rearfoot-strike running may increase loading elsewhere, including the:

Heel and knee.

The cornerstone of treatment is:

Training-load modification, rehabilitation, and gradual return to running, with surgery reserved mainly for selected high-risk stress fractures.