Transcript 馬拉松路跑常用的物理治療評估與諮詢

Physical Therapy of
Marathon Runners’ Injuries
-- Assessment, Judgment, and Consultation
2006年ING國際超級馬拉松行前訓練
柴惠敏
台灣大學物理治療學系
951216
2006年ING國際超級馬拉松行前訓練
Epidemiology of Marathon Runners
• in US, 2002
– 375 marathons & ~ 450,000 completed one
– 30,000 in the largest marathon with 43% > 40 y/o
USA Track and Field Road Running Information Center, 2003
• ING Taipei International Marathon, 2005: 60,000
• finished time (median)
– male: 4 hours and 20 minutes
– female: 4 hours 56 minutes
• to seek medical attention during or immediately after
completing the race: 2% to 8%
– 17% of them MS problems
– muscle cramps, blisters, and acute ankle and knee injuries
2006年ING國際超級馬拉松行前訓練
PT of Marathon Runners’ Injuries
-- Assessment and Treatment
• Biomechanical concerns of running injuries
• Physical therapy assessment
• Skills required for a PT on race day
2006年ING國際超級馬拉松行前訓練
Running Cycle
• stance phase
foot strike
mid-support
take-off
• swing phase
follow-through forward swing
foot descent
2006年ING國際超級馬拉松行前訓練
Shock Absorption at Foot Strike
• ground reaction force at FS = 2.5～3 BW
• biomechanical requirements at FS
– LE motions
• knee flexion, tibia internal rotation, and subtalar pronation
– cartilage or fat pad
• heel pad, metatarsal pad, meniscus, IVD
– extrinsic factors
• running shoes with large heel flare or
cushion shoes
• taping, shoe insole, or FFO
• running surface
gel heel pad
2006年ING國際超級馬拉松行前訓練
Patterns of Foot Strike
• heel-strike
– for long-distance runners
• midfoot- or total-sole strike
• forefoot- strike
– for sprinter only
– long-distance runnner 
metatarsalgia or stress
fracture of central rays
frontal plane section
of heel pad
metatarsalgia of central rays
2006年ING國際超級馬拉松行前訓練
Lateral Heel Flare
heel flare
• lateral heel flare 
 moment arm 
rapid pronation 
prevention of ankle sprain
posterior view
of shoe
2006年ING國際超級馬拉松行前訓練
Heel Cup
heel pad atrophy
use of heel cup
2006年ING國際超級馬拉松行前訓練
Foot Motion during Mid-Support
• foot pronation at mid-support in order to make the
foot more mobile for further shock absorption
• foot pronation  medial and
inferior glide of talus and
internal rotation of tibia
 COG shifting medially   energy consumption
and time to re-supinaiton
• strategy: hard counter for
controlling COG motions
counter
2006年ING國際超級馬拉松行前訓練
Re-supination at Take-off
• re-supination at take-off in order to make the foot
rigid and support the body weight
– LE motions：subtalar joint supinaiton、midtarsal
joint locked, first ray plantarflexion, and MP joint full
extension
– windlass effect of plantar fascia
•  ground reaction force   momentum (= mv)
–  running speed
–  impact force (= Ft) accumulated at metatarsal
heads  metatarsalgia
2006年ING國際超級馬拉松行前訓練
Windlass Mechanism (Truss Model)
Toe neutral
plantar fascia
PF of 1st ray
Toe extension
plantar fascia
2006年ING國際超級馬拉松行前訓練
Arch Support in Pronated Foot
• pronated foot  lower arch
 plantar fascia stretched
plantar fascia
• A arch support would further
stretch plantar fascia
arch support
2006年ING國際超級馬拉松行前訓練
Lower Extremity: High-risk in Injuries
• pronated foot: functional low-arch
• supinated foot: functional high-arch
• tight Achilles tendon
• tibial varum
• bow-leg
pronated foot
2006年ING國際超級馬拉松行前訓練
Functional Foot Orthosis
• to maintain subtalar neutral position
• to dissipate foot pressure
2006年ING國際超級馬拉松行前訓練
Foot Types
supinated foot
neutral foot
pronated foot
2006年ING國際超級馬拉松行前訓練
Characteristics of Pronated Foot
 arch height
WB
STJ neutral
callus beneath 2nd and 3rd MTHs
2006年ING國際超級馬拉松行前訓練
PT of Marathon Runners’ Injuries
-- Assessment and Treatment
• Biomechanical concerns of running injuries
• Physical therapy assessment
• Skills required for a PT on race day
2006年ING國際超級馬拉松行前訓練
Common Musculoskeletal Problems
in Marathon Runners
• etiology
–
–
–
–
 intensity or time
mal-alignment of WB joints
LBP
Insufficient or lax flexibility
muscle weakness or
Achilles
imbalance
iliotibial band
tendinitis
– poor posture
friction syndrome
– poor running surface
stress fracture patellofemoral pain
– improper shoe fit
shin splint
metatarsalgia
plantar fasciitis
heel pain
2006年ING國際超級馬拉松行前訓練
Achilles Tendinitis
• etiology: Archilles tendon tightness
• predisposing factors
– sudden change in intensity
– uphill running
• S/S
– Achilles tendon pain or stiffness
– unable to raise on the heel, deep squatting, or stretch
Achilles tendon
– enlargement of Achilles tendon
2006年ING國際超級馬拉松行前訓練
Distinguish Tendinitis from Sprain
• pain on stretching in both conditions
• different anatomical location
• pain on isometric resisted test
– tendinitis: positive
– ligament sprain: negative
resting
resisted
test
stretch tendon
muscle fiber
tendon
2006年ING國際超級馬拉松行前訓練
Rupture of Achilles Tendon
• S/S
–
–
–
–
–
sharp pain, like be “kicked”
tenderness, swelling, or ecchymosis
dump at the rupture site
unable to one leg stance
positive Tompson test
2006年ING國際超級馬拉松行前訓練
Plantar Fasciitis
neutral foot
plantar fascia
pronated foot
2006年ING國際超級馬拉松行前訓練
Anterior Compartment Syndrome
• shin splint
• muscles within anterior compartment:
– tibialis anterior
– extensor hallucis longus
– extensor digitorum longus
• pathology
•  intramuscular pressure compression of
muscle or vessels
2006年ING國際超級馬拉松行前訓練
Patellofemoral Pain Syndrome
• chondromalacia
• etiology
–
–
–
–
–
lateral tilt of patella
genu valgus
tibia torsion
pronated foot
excessive Q-angle
Q angle
2006年ING國際超級馬拉松行前訓練
Iliotibial Band Friction Syndrome
• lateral knee pain at 15-30 of knee flexion
2006年ING國際超級馬拉松行前訓練
Poplitus Tendinitis
• etiology
– downhill running
• S/S
– pain at resisted tibia rotation at
90 of knee flexion
popliteus
posterior view
2006年ING國際超級馬拉松行前訓練
Stress Fracture of Pars Interarticularis
Superior facet
transverse process
Inferior facet
2006年ING國際超級馬拉松行前訓練
Rotator Cuff Tendinitis
• S/S
– shoulder stiffness, pain, or weakness
– unable to raise the arm or put the hand on sacrum
– drop arm test
• differentiation
–
–
–
–
–
supraspinatus
infraspinatus
teres minor
subscapularis
long head of the biceps brachialis
2006年ING國際超級馬拉松行前訓練
Rhabdomyolysis
• 肌纖維溶解症
• occurrence: downhill running
• S/S:
– muscle pain, low-grade fever, and dark urine after racing
– muscle swelling, tenderness, and weakness are rare
• laboratory examinaiton
– serum CK with a level > 5X of normal value
– 2 ~ 12 hr after injury and peak in 1 ~ 3 day
• Rx
– close monitoring for renal, cardiac, and metabolic complications
coupled with early and aggressive hydration
2006年ING國際超級馬拉松行前訓練
PT of Marathon Runners’ Injuries
-- Assessment and Treatment
• Biomechanical concerns of running injuries
• Physical therapy assessment
• Skills required for a PT on race day
2006年ING國際超級馬拉松行前訓練
Eccentric Exercises
離心運動訓練效果快
但易造成肌肉痠痛
向心
離心
向心運動動作與重力反向，收縮肌肉縮短
離心運動動作與重力同向，收縮肌肉拉長
2006年ING國際超級馬拉松行前訓練
開放鍊運動
閉鎖鍊運動
open kinematic chain exercise
closed kinematic chain exercise
distal end free in the air
distal end fixed on a point
for mobility
for stability
2006年ING國際超級馬拉松行前訓練
Embedded Padding in Shoe Insert
lateral wedge
medial wedge
metatarsal pad
heel pad
2006年ING國際超級馬拉松行前訓練