ABSTRACT
Background and Purpose: Running is a functional activity of daily living for many individuals. Running is not simply for sports participants or the marathon runner. Along with recreational activities, many run for work requirements, educational standards, and achievement of developmental motor skills. The purpose of this article is to define running as a functional activity of daily living, identify risk factors for common running injuries, and propose an evidenced-based model supporting the orthopedic physical therapy rehabilitation of running injuries. Methods: An effective approach for treating non-traumatic running injuries was developed by conducting a thorough review of the literature in conjunction with independent clinical experience. Findings: Understanding proper staging of patients running injury and its accompanying stage-specific rehabilitation can improve functional outcomes. Clinical Relevance: Physical therapists are experts in the treatment of musculoskeletal injuries, and it is important to identify, evaluate, and treat running injuries with the goal of return to functional running.

INTRODUCTION

Running is more dynamic, demands greater weight bearing, and stresses soft tissues more than walking; therefore, the chance for injury is greater with running. These injuries are most often non-traumatic and musculoskeletal in nature. It is a common misconception that running injuries occur in only the athlete who participates in races or sport. In reality, the ability to run is actually a functional activity of daily living for many noncompetitive individuals. There are an estimated 4.1 million runners in the United States; this is a 30% increase since 2000. Of these, 69% do not participate in races.1 These 2.8 million people do not run simply to participate in running, they run because it is a necessity; it is a functional part of their lives. For many, the ability to run has a direct impact on their capability to perform their jobs, participate in required physical education class, and maintain health. Hence, running is a required functional activity of their daily living (ADL).

The various branches of the United States Military each have a specific physical abilities test that includes minimal running distance and time requirements for initial enrollment, maintenance, and promotion. The army holds soldiers to specific standards upon which they are continuously tested. These standards ensure that soldiers are physically able and prepared for the demands of combat. One critical component of the Army Physical Fitness Test (APFT) requires a 2-mile run. Soldiers are consistently tested for their ability to complete this run in a timely manner based on gender and age standards. Army training guides also outline expectations for sprint and running agility.2,3 Furthermore, promotion into special operations, such as Green Beret or Army Ranger, requires advanced running speed and agility.

All other branches of the military hold similar running standards for entrance, maintenance, and promotion. The United States Air Force requires members to complete 1.5 miles and the Marines run a minimum of 3 miles.4,5 The military uses these standards to ensure cardio respiratory endurance and the endurance of the lower extremity muscles. The ability to perform at the required running standards is a means to prepare soldiers for the life and death situations they may face in combat.

However, military personnel are not the only professionals required to run. Police officers, fire fighters, paramedics, and lifeguards are only a few professions where one’s ability to run could mean the difference between life and death. States vary on the required running distance, but many states have adopted the Police Officers Physical Abilities Test (POPAT). Every police precinct has a specific abilities test, and officers are required to run anywhere from a 300 meter sprint up to 1.5 miles.

Adults are not the only patients we may see with goals to return to functional running. Standardized developmental charts define running as a motor skill acquired between 2 to 3 years of age.6,7 The mastery of motor milestones are critical in a child’s ability to progress through motor development and build upon mastered skills. Running is a critical component of this progression. Furthermore, as these children age, their ability to run substantially affects their ability to participate in physical education class at school. Not only do these children need to run in order to participate in organized sports such as soccer, football, volleyball, and baseball, but many physical education programs have adopted the Presidential Fitness Challenge which encourages health and physical fitness. Every student is tested, and timely completion of a 1 mile run is required in order to meet the challenge.8 The goal of the Presidential Fitness Challenge or any running requirement is to develop and assess physical fitness with a functional physical activity.

EVALUATION AND TREATMENT OF RUNNING INJURIES

With dynamic physical activity, such as running, there is a chance for musculoskeletal injury. Studies estimate ranges of 20% to 80% of runners incur at least one injury each year.9,10 Although risk for running injuries is multifactoral, several specific risk factors have been identified. Training errors, the number of miles run each week, and inexperience are extrinsic risk factors. Specifically, inadequate running equipment, less than 3 years of running experience, and improperly increasing frequency, velocity and duration of running is associated with the highest risk for injury. Intrinsic factors associated with injury include muscular flexibility and strength imbalances, prior injury, and positional/postural malalignment.11,12

There are over 20 different running injuries with 70% to 80% of injuries occurring from the knee and below. Patellofemoral pain syndrome, shin splints, Achilles tendonitis, stress fractures, plantar fasciitis, iliotibial band syndrome, patellar tendonitis, and ankle sprain are among the most common injuries.13

Treatment of specific injuries should focus on the patient’s individual impairments, movement dysfunctions, and the efficient return to running as the ultimate functional goal. Impairments associated with musculoskeletal running injuries include: pain, edema, inflammation, muscle strength and mobility imbalances, altered timing of muscle firing, muscle fatigue, muscle weakness, ligament and tendon impairments, impaired joint range of motion (ROM), and biomechanics. These impairments alter neuromuscular control, proprioception, and present with associated movement dysfunction.14,15 Hence, running performance is effected.
Initial treatment of running injuries begins with determining the severity of the injury in order to clinically stage at what point to begin the patient’s rehabilitation. A proposed system for staging running injuries is outlined below.

•  Stage 1: Pain upon exertion

•  Stage 2: Pain at rest

•  Stage 3: Pain that interferes with ADLs

•  Stage 4: Pain that is managed with medication

•  Stage 5: Pain that is crippling

Staging running injuries provides insight into the severity of a particular injury and general prognosis. As injuries present in more advanced stages, the time spent in the early phases of rehabilitation is likely to be longer. For example, a patient who is unable to walk normally with severe edema concurrent with a Stage 5 injury that has worsened over the course of four months, will likely spend a fair amount of time in the initial edema and mobility management phase of rehabilitation. The same is true for less severe injuries. If a patient presents with a Stage 1 injury, with no associated edema or mobility impairments, then they will spend little time, if any, in the first phase of rehabilitation. However, staging running injuries should only be a guide, initial placement and advancement into the phases of rehabilitation is specific to each individual and based on the physical therapist’s evaluation and continuous assessment.

One recent case we treated involved a police officer who came into the clinic with Achilles tendonitis. Symptoms began soon after he began improperly training for the running portion of his police officer physical fitness test. He was extremely concerned because his job depended upon his ability to pass this test. His symptoms began approximately two weeks before seeking treatment, and the pain was exacerbated by running and remained for a short time after he stopped. He assured us that he had not taken any medication for this injury; thus, he presented with a stage two injury.

The next step of the evaluation is to identify compensations and dysfunctional movement patterns during either active walking or running, dependent upon the individual’s ability. These dysfunctions vary based upon the stage of injury, mechanism of injury, and individual differences. Bobath originally proposed a problem-solving approach to the assessment and treatment of individuals with disturbances of function, movement, and postural control.16-18 Using an individualized reasoning process, the concept provides a way of observing, analyzing, and interpreting task performance.18 Concepts described by Bobath in the treatment of gait dysfunction apply to patients with nontraumatic running injuries presenting with neuromuscular impairments.

The final step is the manual evaluation of mobility, strength, and neuromuscular impairments. Manual therapy used in conjunction with neuromuscular reeducation, therapeutic exercise, and therapeutic activities should be used to address joint and tissue specific impairments throughout the phases of rehabilitation. Manual therapy is the clinical approach using skilled, specific hands-on techniques used by the physical therapist to evaluate and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion (ROM); reducing or eliminating soft tissue inflammation; inducing relaxation; improving contractile and noncontractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.14,19 Manual therapy, proprioceptive neuromuscular facilitation, and neurodevelopmental treatment should be incorporated appropriately depending on the individual’s learning style and current standing within the proposed phases of running rehabilitation.

PHASES OF REHABILITATION

• Phase One: Self Management, Rest, Restore

This acute stage includes temporary relative rest from running to prevent further damage. PRICE (protection, recovery, ice, compression, and elevation) is implemented and full range of motion of the injured structure is regained. Since the inflammatory response occurs only in the acute stage, modalities should only be implemented during the initial stage of rehabilitation. After the acute phase of injury, there is no significant effect in terms of function, swelling, or pain at rest. However, manual techniques are appropriate throughout the course of rehabilitation to regain and maintain mobility as needed.

Manual mobilization to increase soft tissue and joint mobility has played a significant role in physical therapy practice since practitioners such as Menell and Cyriax described it in the early 1900s.21 Currently, numerous studies demonstrate that manual therapy is an effective intervention for diagnoses associated with a running injury, and several studies conclude that manual therapy is far more effective than the use of passive modalities.22-24 Cleland et al demonstrated that patients treated with manual therapy paired with therapeutic exercise had significantly better outcomes in plantar heel pain and function than those treated with a combination of ultrasound, iontophoresis, crynotherapy, and exercise.22 Crossley et al demonstrated that manual therapy was significantly favored in the treatment of patellofemoral pain syndrome versus a placebo.23 Multiple studies have demonstrated that intervention including manual therapy improve ROM, swelling, and pain in patient’s with ankle sprains versus control groups or those receiving passive modalities.24
Our patient presented with mild posterior ankle edema and limited dorsiflexion range. Therefore, our initial treatment included manual mobilization and education/ demonstration of self edema management techniques.

• Phase Two: Fix Muscle Imbalance and Work on Body Awareness

Musculoskeletal running injuries often result as a partial or complete destruction of the joint and/or ligament receptors.25 It is also likely that the joint receptors that remain intact relay altered afferent information.25 Both physiological changes, the loss of information from mechanoreceptors, and the induced changes of remaining receptor inputs, are considered to be responsible for functional deficits such as poor postural control, delayed muscle reaction time, and muscular imbalances.25 A muscle imbalance is related to tightening of a mobilizing muscle and a weakening of a stabilizing muscle.26 Mobilizing muscles are those that produce movement. They are often big muscle groups that produce high power. In contrast, stabilizer muscles are often smaller and control movement or joint position, working against gravity. Muscle imbalances contribute to postural instability and can lead to inappropriate biomechanical alignment and compensatory mechanisms. Thus, with the aim of improving and optimizing postural orientation, rehabilitation during phase two focuses on the restoration and enhancement of proprioceptive and neuromuscular stabilization. Activities focus on balance, positioning, and posture with emphasis to improve the areas that are distressed during running. For example, our police officer presented with 90 degrees straight leg raise with a dorsiflexed foot on the unaffected extremity and 45 degrees on the affected extremity. To address the inflexibility in the hamstrings, gastrocnemius, and soleus we had the patient perform supine active knee extensions with the hip flexed to 90 degrees and the foot in dorsiflexion.. Emphasis was place on hip, knee, and subtalar neutral alignment while the active stretch was performed. Next, this same alignment was again emphasized with a balance activity. He maintained a single leg stance with hip, knee, ankle and foot in a stable, neutral position while performing the dynamic arm swing associated with running.

Visual, verbal, and manual tactile feedback is used to aid the runner through the stages of learning and skill acquisition during postural and stability exercises. Initially, as the runner is in the cognitive stage of new skill acquisition, feedback is high. As the runner progresses through the associative stage when the basic fundamentals of the task are established, feedback should be adjusted accordingly to further challenge the runner and allow them to self correct. Finally, the runner should achieve a sense of autonomy with the postural and stability tasks and move on to phase three.

• Phase Three: Functional Strengthening

This phase continues to build upon therapeutic exercise and incorporates activities that emulate the crucial components of running that are impaired. After developing postural control in phase two, phase three progresses with more challenging functional tasks to build strength. Postural orientation for task performance requires the interplay between stability and mobility. Muscle activation patterns are determined not only by postural alignment over the base of support in respect to gravity but also by the interplay between closed- and open-chain movements.27

Because of the relative position of the body during weight bearing activity, closed-kinetic-chained exercises allow a functional pattern of movement. It provides multiplanar isometric, concentric, and eccentric contractions. Closed kinetic chain rehabilitation has been shown to decrease shear forces, increase proprioception, and increase muscle group coordination. 28 Blackburn et al demonstrated that closed kinetic chain strength is positively correlated with functional performance and no relationship exists between open kinetic chain strength and function.28 A significant feature of closed kinetic chain rehabilitation is the optimal development of proprioception.

Rehabilitation should focus on re-educating proprioceptors to recreate functional movements in running/athletic performance. Closed kinetic chain exercises are economical, efficient, and an effective means of rehabilitation to achieve the goal of enhancing proprioception, thus gaining lower extremity joint stability.28 Developing proprioception and incorporating intrinsic timing with muscle force are essential for accurately performed functional activity.

Once in Phase Three, our patient performed functional strengthening by stepping up and over a large step in one movement. Verbal and tactile feedback is given for foot placement, hip and knee alignment, and velocity of movement. This closed chain functional stepping exercise enhances proprioception and strengthens the hip, knee, and ankle musculature required for forward propulsion.

• Phase Four: Efficient Return to Running (functional goal is running)

The final phase of running rehabilitation pulls together the skills acquired in the previous phases in order to return to efficient running. Goals of this final phase include: building endurance, power, and running efficiency.

Endurance running is associated with eccentric muscle fatigue, particularly the hamstrings, and eccentric muscle fatigue may be a potential risk factor for knee and soft tissue injuries during running.29 Therefore, eccentric muscle training should be introduced as an integral part of the training program for runners. Plyometric exercises are implemented to build eccentric strength and develop muscle power. Plyometric exercises are high intensity training techniques that incorporate explosive eccentric-concentric muscle shortening to produce a large force.29 The most common plyometric exercises include hops, jumps, and bounding movements. Numerous studies have demonstrated that plyometric exercise assists in increasing the reactivity of the nervous system and improving the efficiency, endurance, and power in running muscles.29,30
Along with plyometric training, the runner should be engaged in running during phase four. Treadmill training using visual cueing from a mirror and verbal/tactile cueing from the therapist provide the best feedback during the cognitive stage. As the runner progresses into the associative and autonomous stages, less feedback is given and the patient may begin a safe run/walk program progressing to achieving independent functional running and discharge from physical therapy. Our patient initially began his return to running with a ratio of four minutes walking to one minute running for a duration of 60 minutes. As he successfully completed this task several times each week, we progressively decreased the amount of walk time concurrent with an increase in time spent running until our patient was able to run continuously.

CONCLUSION

Running is a critical requirement for participation of many activities not only competitive athletics; therefore, it is the therapist’s responsibility to focus on the restoration of the ability to independently and efficiently perform this ADL. By properly staging his running injury and implementing associated stage-specific rehabilitation, we were able to help our patient pass the running portion of his test and return to his work duties. Because most running injuries are musculoskeletal in nature, orthopedic physical therapists must be proficient in staging the injury, identifying the impairments, and implementing an effective intervention program in order to optimally return our patients to participation in functional running.

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