1. Common Knee Injuries in Distance Runners

2. Introduction Runners that average > 25 miles/wk have injury rate > 30% per year Production of better shoes ---> decreased number of foot injuries, but not as effective in protecting knees

3. Introduction Knee has become most common site of injury in long distance runners

4. Biomechanics Rule of “too’s” common in runners Runners court disaster if they exercise too often, too hard, too soon and too much after injury, and attempt treatment too late

5. Biomechanics 67% of running injuries are result of training errors Body needs time to accommodate new stress levels Injury often due to sudden increase in frequency, duration, or intensity of training

6. Biomechanics Running -----> great forces across knee, especially during push off During running, force across kneecap is 7 x body wt.

7. Knee Problems: History High % of runner’s injuries are reaggravation of old injuries High % due to change in running style to compensate for prior injury

8. Physical Exam Thorough exam of knee Limb alignment Heel alignment Examine shoes’ patterns of wear

9. Anterior Knee Pain Termed “runner’s knee” in 1970’s Pain in front aspect of knee Several causes

10. Lateral Pressure Syndrome c/o “pain under kneecap” Increased pain running downhill, or sitting prolonged period in one position Due to poor tracking of kneecap

11. Lateral Pressure Syndrome Tight band on outer portion of kneecap - lateral retinaculum Treatment = conservative (6 mos. VMO strengthening) If fails, lateral release w/ arthroscope Outpatient surg.- 8 wk before running

12. Patellar Instability Maltracking or slight dislocation of kneecap Changes joint compression forces Symptoms of “pain in front of knee” or “knee giving way”

13. Patellar Instability If maltracking is subtle, treatment conservative -VMO strengthening If strengthening fails, lateral release for subtle maltracking If major maltracking, realign kneecap

14. Patellar Tendinitis Inflammation of patellar tendon “Jumper’s knee” but common in runners Symptoms = pain in front of knee just below kneecap

15. Patellar Tendinitis Excess stress on tendon ---> “microtears” Pain comes on gradually during run Runners often “run through it”, but as tendinitis worsens, often cannot run

16. Patellar Tendinitis Easily diagnosed by physical exam Treatment = REST, Iontophoresis in therapy DO NOT allow M.D. to inject cortisone in this region (may lead to rupture!)

17. Patellar Tendinitis If no relief w/ 3-6 mo of rest, get MRI Depending on severity of findings on MRI, may surgically excise area of pathology

18. Meniscal Tears Meniscus = “shock absorber” of knee Torn meniscus uncommon in young runners, but very common in middle age runners

19. Meniscal Tears Young runner - torn meniscus usually secondary to inciting incident (twisting injury) Middle aged runner - gradual onset of pain/clicking

20. Meniscal Tears Recurrent swelling “Catching” in knee “Giving way” or “locking” in younger runner Great difficulty squatting

21. Meniscal Tears Easily dx by exam Definitive dx = MRI Treatment = arthroscopic repair vs resection Back to running in 4-6 wk

22. Stress Fractures common in runners usually in mid to lower tibia (shin) less commonly, just below knee

23. Stress Fractures local tenderness, pain, swelling (+ bone scan) Rx = REST until symptoms abate

24. Degenerative Arthritis Significant rise in runners age 60-70 No direct evidence citing running as a cause of arthritis With older runners, arthritis more commonly seen

25. Degenerative Arthritis Will running accelerate arthritis? Answer: YES

26. Degenerative Arthritis Must modify running program once Dx made Begin cross-training w/ biking, swimming, non-impact activities Arthroscopic “clean up” effective in only 65 %

27. Iliotibial Band Syndrome Pain = outer portion of knee Aggravated by running downhill Pain starts at 1-2 miles, progresses, and ceases after run Usually no pain w/ other sports

28. Iliotibial Band Syndrome “Bow-legged” alignment ? “Turning in” of forefoot Weak hip abductors ---> pelvic sag---> ITB Wear on outer sole of shoe

29. ITB: Treatment Stretch ITB Strengthen hip abductors Steroid injection vs iontophoresis Surgery = LAST RESORT !! –Partial release of ITB –Out for 4 wk

30. Summary Most injuries will resolve w/ modification of training program May need change in running surface, style, shoe, or mileage

31. Training Program May not need to stop running May need to reduce mileage, intensity Cross-train !! Aqua-jogging ---> non wt.bearing aerobic workout - maintains strength, endurance, mobility

32. Shoe Types Motion Control Shoe - prevents pronation Cushion Shoe - for rigid arches; provides more flexibility Support Shoe

33. Muscle Reconditioning Must restore muscle strength, endurance after all injuries If deficits persist - runner modifies running style ------> different injury !

34. Conclusions Knee remains most common site of injury in runners Most injuries are due to training errors Remember “Rule of Too’s”

35. Conclusions Avoid surgery at all costs!! Most injuries can be treated w/ modification of training program, NSAIDS, P.T., time!!! Remember: HAVE PATIENCE

36. S.L.A.P. Lesions in the Throwing Athlete Wayne T. Luchetti, MD Hampton Roads Sports Medicine

37. Treatment of Shoulder Instability in the Throwing Athlete

38. The Female Athlete: Treatment of Sports-Related Problems

39. Graft Selection in ACL Reconstruction

40. Introduction Complex issue Must consider material properties of graft (graft strength) Consider needs of patient

41. Introduction Patient weight, size, sex Patient’s activity level Type of sport Job requirements

42. Graft Types Bone-patellar tendon-bone Allograft (cadaveric achilles, b-pt-b) Quadruple Hamstring

43. Bone-Patellar Tendon-Bone Central 1/3 of patellar tendon w/ bone plugs Most common graft in USA “Gold Standard”

44. Bone-Patellar Tendon-Bone Convenient - 1 incision ; readily available Bone block allows excellent fixation w/ screws Bone block allows bone to bone healing

45. Bone-Patellar Tendon-Bone Animal studies - graft shows faster incorporation than allograft Ultimate strength initially greater than native ACL

46. Bone-Patellar Tendon-Bone Loses 50% strength over time ---> strength approaches native ACL Among graft choices, shown to have greatest strength in most biomechanical studies

47. Disadvantages Anterior knee pain (16% in some reports) Patellar tendinitis Patellar tendon rupture, patellar fracture

48. Disadvantages Don’t recover motion as quickly ? increase in Quadriceps weakness May not be available in revision cases Increased operative time

49. Bone-Patellar Tendon-Bone Ideal candidate = high performance athlete who requires intense rehab / future performance Prefer no hx of patellofemoral Sx Larger athletes

50. Hamstring Graft Harvest semitendinosus and gracilis - 2 cm incision Quadruple loop ---> size and strength approaches bone-p.t.- bone graft

51. Hamstrings: Advantages Smaller, more cosmetic incision Lower complications from harvest Earlier return of motion; less pain ? Less anterior knee pain later

52. Hamstrings: Disadvantages No bone to bone fixation - weaker initial strength? Some feel rehab should be less aggressive due to decreased initial strength

53. Hamstring Graft Ideal candidate - smaller female athletes Any athlete with hx of patellofemoral pain Athletes who do a lot of kneeling (baseball catcher, volleyball players)

54. Allograft Harvested from cadaver Achilles tendon & patellar tendon most common Risk HIV transmission = 1 in 1.7 million

55. Allograft Controversial evidence that immune response occurs Controversial evidence - graft incorporates more slowly

56. Allograft Some studies show lower knee scores at f/u Slightly more inconsistent results ? increased laxity at 2-5 yrs

57. Allograft: Advantages No harvest site morbidity No size deficits Faster surgery Smaller incision

58. Allograft: Disadvantages Infection risk (but negligible) Possible immune response (effusion, tunnel enlargement) Increased $$

59. Allograft: Disadvantages Slower healing rate Less predictable results ? increased laxity at 2-5 yrs

60. Allograft Ideal candidate = older athletes who put less stress on knee and may tolerate slightly looser knee in return for decreased stiffness/patellofem. pain