All right. Thank you all for coming. My name is Sarah Reiser. I'm at the University of Virginia Runners Clinic. And we're going to be presenting the clinical evaluation of the runner today. We're primarily going to be focusing on the musculoskeletal evaluation today. Plenty to address from that standpoint. I've got three speakers here today. Dr. Robert Wilder is going to start us off talking about physical exam of the runner. I'm going to be talking about run gate evaluations in the office. And then Dr. John Cianca is going to be talking about ultrasound applications and running related injuries. So without further ado, Dr. Robert Wilder. Well, thank you, Sarah. Appreciate being able to be a part of this. So Sarah has asked me to talk about the evaluation of the injured runner in the office. What I'm going to present today is something that's been evolving, you know, really over the past 35-ish years. I think back to it was probably 1990 or 91 when I attended an American Physical Therapy of Association course called When the Foot Hits the Ground, Everything Changes. Show of hands. Anybody attend that course? I know I'm dating myself here a little bit, but nobody. But from that, just taking things that over the years has seemed to be pertinent and important in helping us guide, you know, clinical information that's important as we put together treatment programs for our runners. And that's what we'll be reviewing today, the office-based static exam and functional exam. And then we'll take over with the gait exam. So there we go. So what do we want to do today? We want you to understand the principles of transition and the principle of culprits and victims. And if you get anything out of my 20 minutes, please make that what you take home. We want you to be able to perform a running-specific history, detail to identify potential training errors that led to injuries. Want you to be able to understand the steps that we use in performing a biomechanical screening as well as a functional assessment in the office so that we can identify physical risk factors for running injury. So the principle of transition and culprits and victims. Principle of transition says that running injuries happen when something has changed. So when we do our history, that's what we're focusing on. And sometimes it's obvious. It's the runner that just jumped into a training program and way increased their mileage or started doing several intense sessions per week. It's not always that obvious, though. It may be something as simple as a change in the surface, a change in the shoes. Change in the brand or model is a little more obvious. But sometimes even just buying a new pair of the exact same model can be that transition because shoes change. And that may be enough to have caused an injury. So we try to seek out what has changed. And almost always there's something that we can identify that we can help them with. The principle of culprits and victims speaks to more of the physical aspects of our examination. So the victim is the injury. It's the plantar fasciitis. It's the Achilles tendonitis. The culprit are the biomechanical factors that may have led to this, malalignments, weaknesses, imbalances. And that's what we want to seek for in our examination. So we do a running specific history. We do a biomechanical assessment. It adds five minutes to your exam. We do a functional screening, site-specific exam. Look at the shoes. It's an important component. Make sure that they're right. Make sure that they're not too old. Dynamic examination. Always look at your runners walking and running. Things change. We move from the table to walking to running. We see different things and it's not always what you'd necessarily predict just by looking at them statically. Of course, ancillary testing is necessary. History. What are some things that I ask them? I always ask about their prior injury history. Number one risk factor for running injuries, prior injury. Certainly for stress fractures. So we want to know what their injury history is and if we have a pattern. What team or club do they run for? For me, that tells me what their running training demands are. We want to identify transitions. So I'm asking them some detailed questions about their training and not just recent changes. I want to go back three months, six months, because that's when the transition may have occurred. So you want to start inquiring a little bit further back than just immediately. We all know about the 10 percent rule and it's not a bad rule. It's a nice general rule where it says if you increase your mileage more than 10 percent per week, then you're at risk for injury. But again, it's more than just mileage. It's intensity and it's other factors that may not always be just specific to running itself. How many miles a week are they running? We see a bump up in injury rates at 20 miles a week and at 40 miles a week. And I use that in my clinic when I'm advising folks about how much training they can do while they're working through an injury. What's their long run? A long run that's more than a third of the total weekly mileage is a risk factor for injury. Now does that mean that you shouldn't be doing it? No. I mean, especially our recreational marathoners, they're going to necessarily be doing that for their long run, but we add it into their injury risk profile. So it's another factor that we need to consider. How many training or speed sessions are they doing per week? What surface are they running on and has there been a change? There's no specific information in our literature that says specific surface is more injurious than another. But that transition from one surface to another is thought to perhaps be a risk factor. Look at their shoes. Do you think they're the right type for that particular person's foot type and their mechanics while they're running? And ask them how old they are. Typically we preach 350 to 400 miles is the lifetime of a shoe, and after that you can cut the lawn in it, but you shouldn't be running in it. Shoes at that point may not look worn down, so ask them about it, and when you find the folks that have been using them for much longer, it's time to change. How much cross-training are they doing? We're much more sensitive these days to the energy deficiency syndrome. Well, you know, if we don't ask, we're not going to know, and some folks are out there doing a tremendous amount of cross-training in addition to what might seem like pretty sane running schedules. What are their goals and are they reasonable so that you can counsel them on whether or not it's appropriate to pursue those? Ask about other life stressors that could be fatiguing them, taking away their recovery and preventing them from healing from their particular injuries. Sometimes, again, it's not related specifically to running, but they may simply not be getting the necessary rest and necessary sleep that they might need. And of course, with our female runners, always ask about factors related to eating disorders and menstrual irregularities and bone density. Physical examination. So we do a biomechanical screening. We do a functional screening, and again, the two of these together, five, ten minutes max it's adding onto your time. We do a site-specific examination, shoes, dynamic testing, watching them walk and run, and ancillary testing as necessary. Biomechanical assessment, we do in a standing, sitting, supine, side-lying, and prone pattern. Standing, you want to have them, guys with their shirts off, girls in a sports bra, possible, and you want to look at them front, side, and back. And what are we looking at? Well, standing, I always watch them walk first. It gives me a great window into what's going on. We look at them from the front, we look at general alignment, and we're looking head to toes. So I'm looking at their shoulders, I'm looking at their hips, I'm looking at their knees, their foot and ankles. You can get a general estimate of their leg length and whether there's a discrepancy by palpating their iliac crests and their posterior and anterior iliac spines and the greater trochanters. We look at their hip, knee, and foot general alignment. We're looking at patellar position. We're looking at their foot type. Are they neutral? Are they cavus? Are they planus? And bend forward, touch their toes, get a general idea of their hamstring flexibility. And this is a good time to do the functional screening, but we'll go over that in a little bit. Looking at the side, that bottom picture with the cross, remember the cross pelvic syndrome guy? We see this so much in the office, and if these factors aren't corrected, we're probably putting our folks at a disadvantage. But we're looking to see if there's pelvic tilt. We look at their spinal alignment. We can look at dorsiflexion, so talocrural mobility and gastroxoleus flexibility just by having them do a squat and keeping their feet on the ground. I like to see at least 20 degrees of dorsiflexion while they're standing, and you'll be surprised at how many folks you see that are quite restricted. When they're facing away from you, you can look at their spinal alignment, have them bend forward and back, and look at their segmental motion. You can do your sacroiliac testing, looking at their alignment by palpating the posterior superior iliac spines, and then also doing the flexion and fixation test that we'll show in a moment. Look at their rear foot alignment. Are they neutral? Are they inverted? Are they everted? Are they the same? Because you'll see asymmetries if you look for them. Have them do the stand on toes test, looking for tibialis posterior dysfunction. We should see normal inversion as they go up into a standing on toes position. So the SI fixation test, the SI flexion test, as one is lifting their leg up or bending forward, we should see that posterior superior iliac spine slightly rotate posteriorly. If it's rotating anteriorly or staying in the same position, we might have some sacroiliac dysfunction. And then we can see the stand on toes test, where normal inversion indicates that the tibialis posterior is functioning normally. We have them sit on the table, and we do a more detailed pelvic assessment, assessment of the patellofemoral mechanism, and then we can do some flexibility and neurologic testing. So if you saw an imbalance, pelvic asymmetry on your standing examination, and you're thinking maybe they have a leg length discrepancy, check it again while they're sitting. And if things have evened out, probably is leg length discrepancy. If it's still persistent, they might have a pelvic or lumbar dysfunction contributing to it. We can examine the patellofemoral mechanism, looking at the position, looking at their tracking as they're flexing and extending, and feeling for crepitus. So certainly with folks who have knee pain, that's something that we want to be evaluating. We can do flexibility and strength testing. So do your neurologic examination in this position, looking at the dermatomes and myotomes. And then you can also focus on hip flexor strength, knee flexor extensor strength, dorsiflexion, plantarflexion. Laying down, what are we checking in the supine position? We can check our leg length, do a more detailed lower extremity alignment evaluation, looking at femoral torsion, tibial torsion, Q angle. More detailed patellar examination in the sitting or the supine position, especially looking at mobility. And then further our flexibility examination. So the leg lengths, we typically measure from the anterior superior iliac spine to the medial malleolus. I can tell you in over 30 years, I've probably taken the tape measure out a few times. But eyeballing it is important, and making note of any asymmetries that we see. We look at femoral and tibial position, as well as the Q angle. We expect to see some degree of femoral anteversion in our patients. Femoral retroversion has been linked to a number of lower extremity injuries, in particular stress fractures in general. Tibial torsion, we expect to see about 15 to 25 degrees of external tibial torsion. And again, we're also looking at symmetry in these folks. Q angle, 10 degrees for males and 15 degrees for females is considered upper limits of normal. Again, rarely am I taking out the goniometer, but I am at least eyeballing these and making a guesstimate and judging whether things look symmetrical as well. Our patella examination, especially in folks who have what looks like patella femoral pain, having knee pain, get your hands on them. Palpate that patella, the peripatellar region. Get your thumbs underneath the patella and palpate. Feel the femoral condyles. It can guide you as to whether you are now really thinking that they might have some patella femoral syndrome or cartilaginous injuries. Look at the patella tilt. You should be able to lift that patella up 5 to 10 degrees. And again, this is something that we're guesstimating, and we're also looking at symmetry. Look at patella glide. Not all patella femoral syndrome is the same. Some people have normal patella mobility. Some have hypermobile patella. Some folks are going to need more stability. Some folks are going to need some manual therapy to improve the mobility. So looking at that patella glide mechanism and seeing how much mobility they have, an important component. Flexibility, Thomas test, looking at hip flexor flexibility. Also allows us to look at hip internal and external rotation. Again, important component of the exam, and you'll see quite a bit of asymmetry in folks that can be corrected with appropriate manual therapy and exercises. Pop the teal angle, looking for hamstring flexibility. And the side-lying position, over-testing to look for IT band flexibility, and then also abductor strength. And Mike Fredrickson, who's speaking with us in the next session, he talks about his two-finger test, where he would say, if I can overcome their hip abductors by pushing on the ankle and pushing them down with two fingers, they're at risk for injury. I mean, what's that? One finger. Yeah. Mike uses two, but yeah. Mike uses two, but yeah. I mean, and it's not, I was going to say, that's weak. It's not always an absolute strength issue. Sometimes it's just an engagement issue. They're not firing those muscles. But you'll see a tremendous amount of asymmetry in the office side to side, but you'll also see folks that are, you know, I've had rugby players in the office and two fingers, and I've had 100-pound distance runners that I could do push-ups on their legs and not get them to budge. So it's not always what you would expect. But if there's weakness, we want to correct it. The prone examination, look at quad flexibility by doing heel to bum. You can look at dorsiflexion in the open chain position. I like to see at least 15 degrees. We can look at hamstring strength, both at the hip and the knee, so hip extension and knee flexion and looking for symmetry. Subtalar motion, mid-tarsal mobility, and our subtalar neutral examination. So let's look at those. Subtalar motion, inversion, and eversion. I want to see 10 degrees of eversion and 30 degrees of inversion, and I want to see symmetry. And if they're lacking, they might need some manual therapy to improve that. Mid-tarsal mobility. Grasping the calcaneus and holding that stable as I'm moving their midfoot into inversion and eversion. And again, symmetry becomes important. We put them in subtalar neutral, which means I can palpate that talus on either side with my thumb and index finger equally. It just gives us a common identification point. And I'm going to look at alignment, leg to rear foot, rear foot to forefoot. And I can classify that as neutral. Varus or valgus. And again, symmetry is important. Can look at first ray mobility and great toe extension. So subtalar neutral exam, leg rear foot alignment. This one looks pretty neutral. Rear foot forefoot alignment. So we're looking at the alignment between the heel and the mid-tarsal heads. And again, classifying it as neutral, varus or valgus. Looking at first ray mobility. How many folks check first ray mobility in the office? Yeah. Good number, which is good. So as you're checking that, we want to see that first ray being able to be brought down to the bottom of the second ray and then to the top of the second ray. Folks who don't have good mobility in their first ray or folks who have excessive mobility in their first ray are going to have elements that transmit up our kinetic chain and may need to be corrected. Look at that great toe extension. I mean, this is an important part of our running gait cycle as we're going into toe off. And if we don't have good mobility or we have asymmetries, it's going to cause side-to-side differences. The sole of the foot can give us a pattern of how they're loading while they're running. Of course, our site-specific examination now. And these are the steps I always encourage our residents to do. Inspection, palpation, range of motion, neurologics, and special tests. Our functional screening exam. There's a whole number of tests to look at lower quarter stability. Single leg stance, single leg squat, bilateral squat, isolating the flexor hallucis brevis, the step-down test, the swing test. The ones that I use most commonly in the office, I'll look at single leg stance, single leg squat, and I'll use the flexor hallucis brevis isolation test. The swing test and the step-down test are a little bit more dynamic. But basically, we're looking for the ability of the runner to stand steady. Keep their hips steady. Keep their leg in a stable position without cross-adducting and internally rotating. We don't want to see them collapsing into excessive pronation because they can't maintain stability during these tests. If they can't do them during these tests, it's going to be very difficult to do it while they're running. The flexor hallucis brevis isolation test, very simple. Get their foot neutral. Have them keep their big toe down and the little ones up. And you'll be surprised. As you see, numerous folks go through this. Some folks can nail it right off the bat, and some folks are tremendously unstable. And again, you ask the question of, geez, if you can't keep yourself stable in standing position, what's happening while you're running? Shoes. It's an important component to ask about. Shoes are certainly one of those things where one size does not fit all. So you want to make sure that in your mind, it's fitting their mechanics appropriately, it's fitting their foot appropriately, and that they're not old and worn. Dynamic exam. Again, watch people walking and running, and Sarah's going to be covering that. Ancillary testing is necessary. And with that, you can't buy happiness, but you can buy running shoes, and that's pretty darn close. So that was a travel through an exam, and I did it in 19 minutes instead of 20. A lot of steps there. You've got the handout. Am I allowed to call out the textbook of running medicine? We've got a chapter in that that goes into this in detail, and it really goes through sequentially and is a nice recipe to collect these different data points so that you can hopefully design some rehabilitation programs that will be more meaningful for your runners, especially those who have been having chronic injuries and the standard types of treatment haven't been able to get them back on the road. Thank you. So I feel a little bit of a sense of relief having Dr. Wilder talk first, because I always feel this need to talk about all of these things before I jump into Rungate, and so that usually looks like about three slides, which is never sufficient. So I'm going to talk about how we can now use Rungate analysis to help complement our evaluation that we look at in the office, more static and dynamic exam off the treadmill. So, again, I'm Sarah Reiser, talking about Rungate Evaluations. Financial disclosure is not pertinent to this talk. We're going to talk about Rungate Evaluations and how we can use this information to manage our runner. So I want you to think about a case. This is a 19-year-old competitive collegiate distance runner. He shows up and ends up having a diagnosis of a high-grade proximal posterior tibial stress fracture. And what is the role going to be of Rungate Evaluation in this person's recovery? So the biggest takeaway for this talk, you don't know how a runner runs until you watch them run. Now, you do the evaluation that Dr. Wilder went through, and you can get a pretty darn good idea, especially the more repetitions you go through, the patterns you start seeing. I have people take off their shoes and apologize for their feet, and I say, don't apologize for them. That's lots of information right there. Give me evidence about what's happening. And, in fact, we've got to fix all of this, because you should not have your feet looking like this. So everything that you see in that evaluation is going to give you good information about what's happening. And at this point, I typically am going to have a good idea of what someone looks like when they run. But sometimes you're surprised. You get them on the treadmill, and they move completely differently, or they fatigue quickly. So like I said, got to get people on the treadmill. This can look like a lot of different things. So this can be a super complicated evaluation with infinite number of cameras and a big setup, a force plate, a PhD who's helping interpret numbers and angles and charts. Or we can do an evaluation with a camera. So it's going to be like a tablet. We get two views, and we give information in real time. Both have really great value. It's really asking, what are your expectations and goals from this standpoint? So with RunGate Analysis, I'm going to give you a little bit of anecdotal information and kind of what I would do in clinic. But I will typically have some level of video software. I use a tablet, take some video, lateral and posterior, usually do a shoe close-up as well so you can get more information about what their motion looks like. And then when I have someone come into the clinic, number one, they have to be healthy. They cannot be in pain. Because if they're in pain, what I'm going to tell them is, you have an intalgic gait. We're going to treat that injury. So we want to make sure they've gotten to the point that they are running typically about 20 minutes continuously and comfortably. So they've got some level of conditioning, and we can get a good idea of what they look like. And typically, I'm having them run at a comfortable pace where they'd spend most of their time on the treadmill, depending on the mileage. I'm going to have them come in form-fitting wear. So we have plenty of spandex on the market these days, so something that's form-fitting. And if they can't remove their shirt, women in sports bras, that's most helpful. But I also give them the option just to tuck in their clothing. We want to get as much information about the spine and pelvis as we possibly can. And early on, I was doing a lot of markup for sake of time. Oftentimes, I'm not doing that anymore. But essentially, you can mark them up posterior and laterally. You can see a couple marks on this person here. The ASIS and the greater trope, which you can put one on the fibular head and the lateral mal. And then also posteriorly on the PSIS, the medial gastroc, and the calcaneus. And that'll give you a little bit more information about what's happening, give you a better visual. So what are we looking for? We're looking for abnormal neuromuscular patterns. We're looking for mobility limitations and asymmetries. And essentially, we're looking for big deviations from the norm. In order to do that, you need to know your normal patterns. So you've got to watch a lot of these and have an idea of what is it that you want to see, and then how can we potentially address any of these deviations. There are limitations with this. So getting someone fresh in the treadmill, we may not necessarily see what they look like when they fatigue. But honestly, I feel like we oftentimes get enough information to inform a physical therapist and next steps in our plan for recovery and preventing injury moving forward. Like I said, repetition, pattern recognition, super important. The more that you do this, the more you're going to see these things. And an experienced physical therapist is really important here. When I do my counseling, I'm going to tell them I really want to hook them up with someone who's going to help with supervision with going through this, because the last thing I want to do is do a Rungate evaluation, give them recommendations, and they go to the other end of the spectrum. And now we have a new pattern of injuries. So making sure that a lot of these adjustments are very subtle. So proposing a Rungate evaluation to a patient, like I said, they've got to be healthy, they've got to be pain-free. I want them comfortable running 20 minutes, so they've got some conditioning and they're feeling comfortable running. It's nice if they've run on treadmill before, because we do know that there can be some changes, treadmill versus overground running. So a little bit easier if we know that they're going to be comfortable on the treadmill. And then set expectations. I also will ask folks to, especially our marathoners, ultramarathoners, do they carry something in their hand when they run? Because I've had some folks that couldn't quite figure out what was happening with their upper extremities, and then it turns out, oh, they always carry a bottle in their left hand. So again, an important part of that comprehensive history. Expectations. So we want to talk about goals. We want to prevent injury, right? And I'd love to do all primary prevention of running-related injuries. I don't think that day will ever come. Typically we're seeing someone who's had an injury, and now they're motivated to prevent another one. And so we're bringing them back from an injury, and so you've already got a lot of history. You've also figured out, well, where's kind of the weakest link? Where do they get an injury when they're not able to keep up with recovery? Sometimes I have people who come in with pain and dysfunction, and it's potentially relatively subclinical, and so I can get them on the treadmill at that time, and we can kind of see what's going on. So that is a small population of patients that I will see in clinic, and we can get them on the treadmill the first time I meet them. And then, of course, optimizing performance. If we're doing more up-and-down motion as opposed to forward motion, boy, if we can translate into forward motion, maybe we make them faster, and everyone likes to do that. Factors that determine Rungate. We've got things that we can't change, like anatomical alignment, but then we've got things like joint mobility, soft tissue flexibility, muscular strength, neuromuscular patterns, balance. And we can affect all those things. Patient education. Super important here. I think it's the most important part of the whole Rungate evaluation, is what are you going to do with this information? So giving patients visual feedback. I always ask if they've ever seen themselves run before, and I have patients who have run for decades and never seen themselves run. And so I say, well, you're going to see it today. So going through things, and I even get, you know, what's their gestalt? What do they think when they take a look at their imaging? And oftentimes, that can be the most powerful information they can get. Verbal counseling is helpful, but after probably the first couple of things you say, they may not absorb everything else. So super helpful to have a written summary they go home with. And trying to kind of, I typically whittle down to three different categories of things that we want to address. And then that communication with the physical therapist is super important, and this is where it's helpful to have that running community. Limitations. They need to be pain-free. They need to be relatively fit. Sometimes we have this chicken or the egg syndrome. So we have someone who's not in weight-bearing for six weeks. We're getting them back to physical therapy, getting their conditioning back up, and then we get them on the treadmill, and it's kind of like, well, you know, is some of the weakness because they were not in weight-bearing for six weeks and we're still trying to recover, or was this what they looked like before? Sometimes they'll even ask if people have video of themselves running before they had their injury, and that can be helpful information as well. There's no one-size-fits-all gate. So I'm not trying to put anyone into a box. I'm trying to minimize risk. And then treadmill versus over-the-ground running. I have had some folks that we do some video over ground, a little bit technically challenging, but I have done it a few times, especially when I have folks like sprinters that it's hard to recreate that on the treadmill. So run-grade evaluations. We want to look at absolutely everything. So you want to have a systematic way that you're doing this. You want to look all the way from the head all the way down to the feet. We can be tempted to look just at the feet and say, someone's over-protonating. Well, the issue might actually be up at the pelvis and the core, but it could also be that they have this huge forward head posture and slumped shoulders and their body's following their head. So we want to make sure that we're looking at the entire picture. What I will typically do is get kind of a whole gate gestalt. So I'm getting on the treadmill, they're starting to warm up, I'm kind of watching their gate real time, and then I'll do my video. I do 20-second videos. And then after that, I'm going to do the systematic interpretation. So I like having that initial gestalt, like, oh, yeah, that's what I thought I was going to see. It makes sense with their pattern of injury that they came in with, but the systematic interpretation makes sure that you don't miss anything. And remember, the symptomatic site is not necessarily where you're going to find the issues, and usually it's not where you're going to find the issues. Go back to the static exam when necessary. So you see something on their run gate and think, huh, I wonder if their hamstrings are tight. I forgot to check that. So oftentimes, I get them back on the table, and I'm checking a few extra things to complement that exam as well before we're having a conversation. So again, there's a number of ways to do this. This is a list of parameters that I learned in fellowship. So I actually have a sheet that I kind of go through and check off. It makes it easy way to make sure that I didn't miss anything. Going through cadence, so the number of steps per minute, and then looking at posterior and lateral views and the different pieces that you would look at. So lateral view, looking at their foot strike, their ankle position at loading. Are they excessively dorsiflexed? Are they overstriding? And what's their shank position at loading, meaning is their knee fully extended, and they're really sending a lot of shock up the chain with increased ground reaction forces. What does their knee flexion angle look like during stance, during swing? Are they activating their hamstrings, hip extension at terminal stance? So are they using their glutes to push themselves forward? Do they have the mobility to do that? What's their pelvic tilt look like, because that's going to really affect your ability to activate glutes, as well as making sure that your core is nice and stable. And then what's their overall impact in the vertical displacement? So again, we don't want to go up and down in running. We typically like to move forward. Basketball, we want to get up to be able to dunk, but in running, we want to cover ground faster typically. And then don't forget your head posture and your arm swing. Arm swing, I worry a little less about. We do sometimes coach it a little bit, but what it's most helpful for is showing you what's happening down below. So if you've got all kinds of crazy things happening with the arms, you've got wide arms, elbows are way out, you're starting to wonder is there some issue with stability or balance. And then posterior view, we're looking for pronation, supination, and it's not just the presence of those things, because pronation is not a bad word. We need it. It's our shock absorption. But how fast is it happening? How much is happening? Can they recover and come back into supination before push-off? Do they have a heel whip? Oftentimes the heel whip isn't an issue. That's an extra motion that's happening at the ankle or the hip as they're coming through with flight phase. But it gives you more of an idea of what's happening up top more proximally. And then do they have a pelvic drop, which is a common thing that we'll see? So that's that hip abduction weakness or lack of activation, trunk rotation, which can give you some insight into the spine, because believe it or not, runners have spines too, and you can't forget about that part too. And arm swing. So here are a couple of images. Oftentimes when I'm going through and reviewing, I'm actually really just looking at all these snapshots in time. So I've already looked in real time. I may drop it down to quarter speed, especially to show the patient. And then I'm looking at specific images. So here you see foot strike, mid-stance, heel off, and toe off. And this is a pretty talented elite runner with pretty decent form. So a lot of good information that you can get from all this. You can see he's pretty stable through all of this as well, has a nice heart-to-pocket arm swing, and has pretty decent turnover and push-off. I don't oftentimes see that good hip extension with push-off. You can draw a line above their head. Again, this is not looking at specific numbers, but giving you a little bit of a gestalt of what's happening. But you can see there's this vertical displacement if you watch what his head is doing. We expect one and a half to two inches of vertical displacement. That's pretty normal, but anything beyond that would be concerning, and he looked okay. And then you can draw a line in front of the center of mass. So right in front of that ASIS, are they landing close to that center of mass? And he sure is. I will say that foot strike is probably just a second after he's actually struck the ground, but he actually is landing pretty darn close to it. So we're not so worried about him overstriding here. And then if we look from behind. So I don't typically look at all of these views from behind. Probably the mid-stance is the most important from my perspective, and it's typically because you're going to see a big excessive pelvic drop if we have a lot of deficiencies that we're looking at. Again, in this case, he is nice and stable. Things look really good. His spine is staying in nice alignment as well. Again, you can draw that line up above their head. So coming back to our case, I'm going to give you like 15 seconds just to take a peek. So all those words that I just gave you, think about what you see on these images here. All right, so, I would have obviously taken a look at this all in real time. I would have already had a big evaluation with him. You do have one piece of information. He's got a proximal tibial posterior stress fracture, and he presents with high grade injury, and he's a collegiate runner, so high level. So, you take a look, his cadence is 156, not bad. We like it to be more like 160 to 180, especially for an elite runner, but again, there's no perfect answer for everyone. And then we take a look at his lateral view. He's got a pretty hefty heel strike with toes straight up in the air, his knees extended, so lots of forces going up the chain, which you can imagine does not make the tibia very happy. And he doesn't have very much turnover, so not a lot of hamstring activation as he's coming through a flight phase. Has almost no hip extension. And he's actually got some posterior pelvic tilt that's happening there, and on his exam, he also had a flat back, and if he did his popliteal angle, it was about 120. I remember, this is in my first year of practice, and I called my physical therapist friend who takes care of runners, and I said, what in the world does that mean? And she's like, it's his back. So, all that neural tension that's happening in his back because you see that big pelvic tilt or pelvic drop in stance phase, that's basically tensioning those nerves and aggravating them, and then your whole posterior chain is getting really tight, so everything's connected. He had some increased vertical displacement, overall impact, again, we wanna send that information, send all of that energy forward. Had almost no excess motion at his foot, which actually wasn't the greatest thing. We wanna work on a little bit of mobility and shock absorption there, but no major pronation or anything else that's happening from that standpoint, no heel whips, but he did have some excessive pelvic drop that we wanted to address as well, and then decreased trunk rotation because his spine was quite tight. So, higher impact loading variables, pelvic drop, excessive forward trunk lean, extended knee, dorsiflexed ankle, all these things are gonna be risk factors for running-related injuries. So, we've already kind of checked all those boxes, and sure, he's injured, right? So, we knew that was gonna be the case when he came in, but those are all things that we can try to affect and try to improve so that we're doing secondary prevention moving forward. We've also identified some things that can potentially make him a faster runner, which is how I got buy-in with him because he was not buying all of this. Here, we can draw that line right in front of that ASIS, and see that he's over-striding. And here, you can see an older counterpart who is running at a much slower pace, also over-striding. So, don't forget about that. Your forefoot runners, you may think, oh, forefoot strike, that's great. Well, if they're over-striding, it causes a lot of problems from that standpoint as well. So, you wanna check all those things. Here's your contralateral pelvic drop, and I did exaggerate this curve just a little bit, but just to emphasize that you have a pelvic drop here, which is affecting a lot of different things, but don't forget the back is really affected here. And so, this is part of what's really tightening up that posterior chain and causing issues distally in the lower extremity. You can bring this back to your single-leg squat. I like to do a video of the single-leg squat and turn it around and show the patient because they don't quite understand how bad it can be until they look at that video. And I like to point out in this particular picture that jazz hands, so that tells you that patient is really trying to balance, and that's an important component of all of us as well. But looking at that knee valgus and that contralateral pelvic drop. So, trying to put everything together, that physical exam that you did in the office without the treadmill is very valuable once you start matching all of these different patterns together. So, biomechanical risk factors for bone stress injuries, all things that we can see on Rungate evaluation, excessive hip adduction, increased knee internal rotation, excessive motion that's happening at the ankle and foot, heel strike, which lots of people heel strike. I don't necessarily try to change them, but if we can minimize some of the extra forces, the over striding, the excessive dorsiflexion angle, we can minimize some of those increased ground reaction forces. Low step rate, longer stride length, higher plantar pressure, so all things that we can address from a physical therapy and gait retraining standpoint. And then we can improve running economy. Again, this is how I got buy-in with my collegiate runner, and in fact, he got much faster and was All-American after this injury. So, I would venture to guess that some of these things were very helpful for him as well. We want to align the legs with the net force vector. We want to maximize the effects of elastic recoil. So, we're really trying to get away from any of this excessive rotational stuff, any of that imbalance or instability that's happening at the core and pelvis is going to introduce all this rotational motion, and we want to get rid of all that excess. So, when we educate our patient, once we've gone through a Rungate evaluation, we want to be really positive with them, so we don't want to get them down, and we're pointing out all of the bad things that are happening. What we want to do is be constructive. So, I'm going to tell you the good things that you're doing with your Rungate, but then I'm also going to tell you what are the things we can fix. What can we try to improve some of those deviations from the norm and try to mitigate some of that injury risk, and also make you feel more comfortable and possibly faster. I'm going to talk to them about the bad. So, the good is the things I want to keep doing. The bad is what I want to potentially address, and then the ugly is what we can't address, right? So, we've got some anatomical alignment issues, we've got knee arthritis, we've got some things that we may not be able to actually change, but how can we moderate some of those effects? There's no one-size-fits-all. We're not trying to make everyone run on their forefoot, but if we can decrease some of those deviations from norm, we can help. I will go through some general principles of running, heart-to-pocket, arm swing, those types of things. Going through the different things that we can address specifically that's personalized to them, and then I always tell people we need to train to run. So, we've got to do the strengthening, we've got to do the extra pieces. It's not physical therapy for six weeks, it's physical therapy forever. You've got to really incorporate these things into your regimen, and this isn't just because you got injured, this should be for everyone. There are some run-gate cues that I will sometimes give folks, but again, I really like for any of these adjustments to be done under physical therapist supervision, but sometimes I'll let people know if they think about running softer, that can be helpful. If they imagine their kneecaps as flashlights and shine them forward so they're not bumping their knees as they're running, it'll help activate some of the hip abductors. Running with their second toe on the line of a track or bike lane, so the other foot is off of that line, can help increase that base of stance, and then possibly some small cadence adjustments, but again, I'm pretty cautious with making those adjustments without having a therapist take a look at them. So, coming back to our case, we've kind of talked about some of these things. So, some poor lumbopelvic mechanics are really the big thing here that we need to address. Really working on deep core muscles, glutes, hamstrings, working on intrinsic foot muscles and balance, and that pelvic drop, we've got to fix that as well. If I recall, I think he was relatively weak with glute me, but actually not terrible. It was really more of the activation patterns. Trying to address his quaddominant gait, reduce that overstriding, and then trying to decrease some of those high loading rate qualities. So, that can look like increasing his cadence slightly as well and trying to get him to land a little bit closer to his center of mass. So, here's a prescription I might send on to a physical therapist. This is a few more words that I might send, but essentially looking at core, glute, hamstring activation, trying to get more of a neutral pelvis, working on hip mobility, toe yoga, which I might hand out on the way out the door, looking at their spinal mobility, periscopular strength and posture, because he also had a little bit of a forward head posture, and then some suggestions in terms of his gait as well. So, in summary, watch people run. You'll be surprised what you see, and it'll also educate you on what you're doing in clinic before all of that. Think about the surgeon who gets information by opening up someone's knee joint, and they go, oh, now I can kind of make that connection of what it looked like in physical exam and MRI, and now we see it in person, and I would liken that to this as well. Have the equipment. It's not too much. You just need to have it on hand and be ready to do it in a timely fashion. Sometimes I'll do these in longer segments, but a lot of times I'll just have someone hop on the treadmill and get a couple minutes to help inform our next steps. Do it repeatedly, start seeing the patterns, and then make sure you're doing the patient education, because that can be one of the most valuable components of all of this. There's no one-size-fits-all when it comes to gait, and have a good team. If you're wanting to learn a little bit more about teams, we are going to talk about putting running clinics together at the session after this. Running can look like a lot of different things, including my toddler at his different stages. So, thank you. Good morning. I'm John Cianca. I have a private practice in Houston, Texas. And just while the slides are coming up, I'll give you a little context. Bob and I probably started evaluating runners when some of you were learning how to walk. So we've been doing this a while. And back many years ago when we started, running medicine really wasn't a thing. Bob and I and a few others, John Halperin, Mike Fredrickson, did a presentation in San Francisco, sort of on this note. And it was on a Sunday morning. Not good. And it was being recorded, but we were the only people in the room. So it's good to see everybody here. And it's good to see how running medicine has evolved. Certainly, Bob has led the way with that. And I'm grateful to be here and contribute as well. So I will say, too, that one of the things you have to differentiate about running from other sports, it's a very repetitive, monotonous task. We're not changing directions. We're not doing different things while we run. You're just running. And so that in itself lends itself to the problems that you'll see with running, which aren't often structural in nature. They're functional in nature. And particularly in the amateur ranks, they're behavioral in nature. Elite runners, I like to think, have pretty good judgment and pretty good sensibility about how to train. Amateur runners, not so much. And there's a lot of bad judgment that comes with them with their injury. So you're going to be, you need to be a functional expert. You need to be a little bit of a psychologist. And it's not a bad thing to understand structure. So what I'm going to take you through, minus my disclosures here, is a picture show of some of the things you will see that Dr. Wilder talked to you about in evaluation. So this is a way to put some visual context to what you believe may be going on. So ultrasound has become a very important tool for me because it connects some of the premise that I gather from history and some of the data I gather from physical exam. And it may say yes or no to those two aspects of evaluation. And then, as Dr. Razor pointed out, looking at things dynamically, very important because people don't just, they're not still when they run. They're moving. You've got to understand what they're doing when they're moving. So maybe they're weak on their physical exam. Maybe they're not. But they could show up as weak when they're running. And that's a whole different thing than just being weak. That's function. That's how are they integrating things. So you really have to take a look, as I think you probably all know, at the whole picture, not just the foot, not just the ankle. How are things interacting? How is that movement integrated? And how does it come out? Does it show up well? Or it's one thing if they test bad, and you know right away you're going to have problems. But if you don't get a real obvious physical exam, then you've really got to consider how they move. So we're going to start with some, we're going to start up top and move down. And these are very sort of concise notions that there's a lot to. But I wanted to give you a feel for what they might look like and what you might not see. So this is the lateral hip. And people refer to greater trochanteric pain syndrome. I don't. I think it comes down to two things at the lateral hip. Radiculopathy, which causes weakness, which can lead to this, which is gluteal tendinopathy. And to some extent later on with older runners, it might be gluteal tears. Bursitis shouldn't jump to your mind as a primary diagnosis. And bursitis, I have a, I'm going to rail a little bit here because I hate bursitis. And particularly the laziness that comes with diagnosing it. Bursitis is a tertiary diagnosis. It's, it, burses are just there. They react when something else has happened. So don't, please, don't make a primary diagnosis of trochanteric bursitis. One, it doesn't exist very often. And two, if it is there, something else is going on. All right? So in this case, we're looking at, Sarah, how's the, what's the pointer again? The button on top. So I, I can't use it. I got to use it there, okay? All right. So in this case, we got the gluteus medius on the lateral facet, gluteus minimus on the anterior facet. And so several things stand out to me in this image. First of all, the gluteus medius doesn't look like it should. It's dark, as opposed to the gluteus minimus, which is bright. That's the way a tendon should be. And it's thick, right? This is at the greater trochanter. It should take up relatively little volume. And the other thing that stands out here is the subtle but definitive cortical irregularity. So while this tendon is not grotesquely torn, it is very dysfunctional. It's thick. It's lacking integrity or echo, echoity. And that's why it shows up as dark. And then it's also, over time, implicated the bone, right? Now, you could see tears with this. In this cross-sectional view, it's not readily apparent. This is tendinopathy. It's not tendinitis. It's not, strictly speaking, a tendon tear. So when you look at a slide like this, you have to be able to understand what your eye is seeing. And that's a central tenet to ultrasound, is an integration of visual to understanding of what that means, right? So that's one of the tasks of learning ultrasound. Now, on the image on the right, I'm going to actually show you where a trochanteric bursa is. So here's the gluteus medius. This is gluteus maximus. And right, that little thin black line is where the greater trochanteric bursa would be. And there are some cases where it'll exist and be inflamed. But never, unless somebody fell on their hip, it's not going to be the primary diagnosis. And another point about evaluating runners, it's very rarely an incident. It's most often a problem that develops, right? So it's an overuse injury, but more of a training injury. It's what they do that gets them there, not what happened to them. And that may be a product of their alignment, sometimes their anatomy, but more alignment. And then, again, what do they do that gets them in this situation? So you've got to start thinking functionally as soon as they walk into the door, as opposed to somebody like a lacrosse player or a soccer player or a field hockey player who are all running, but they're doing other things. A runner just runs. And they run in one direction, usually. It's a very sagittal plane activity that in the coronal and transverse planes are your stabilizing planes, right? So the problems that develop when running are often in the transverse and coronal planes, leading to a lack of performance in the sagittal plane, right? So you can't really run well if you're weak in the coronal plane, weak in the transverse plane. Your sagittal plane suffers. Your propulsion suffers. Another way to think about running is a series of jumps. You jump, you land, you jump, you land, over and over again. And it's how you land that dictates how well your next jump will be. So in looking at a gait analysis, to me, in the analysis, one of the most important things to look at is what do they look like in stance phase? Because that's going to tell me what happens when they try to move forward, either with speed or with any sort of successful repetition. So the hip is often one of the primary drivers of instability. Weak or not, right? They may not test out weak, but they may function weak. And that is usually in the coronal plane, but often combined with the sagittal plane. So if you see in a gait analysis that they're weak, you may not see problems on an ultrasound. You may not test out weakness on exam. So again, you've got to rely on all these things to help you get to the right diagnosis. And I would say, probably, that functional analysis is the most important. OK, so now with more lateral hip. In this case, we're looking at a very thick, and this is unusual, a very thick iliotibial band. That's really thick. And on the slide on the right, you can see above the gluteus minimus, medius, and tensor fasciae latae is this thickened band. That's the IT band. And I don't recall if this person was a primary runner or just ran as well, but she had a very thickened iliotibial band, which led to this snapping that was occurring when she walked or ran. And that was painful, of course. So this is an unusual finding. Most often, iliotibial band is going to show up at the knee. But just be aware that the proximal iliotibial band can be a problem area as well. And here you see the iliotibial band sliding over the hip with internal and external rotation. Let me go back and do that again. And I think you can see. Oh, can I replay that somehow? Well, I won't belabor the point. But the iliotibial band has to slide over that trochanter. And if it's really thickened, it could actually snap. Now, it's not the most common form of snapping hip, but it is something to think about. And particularly, that person may feel it, or you may feel it when you examine them. OK, now, this is exceedingly common. The posterior hip, namely the hamstring origin, is a common source over time for degenerative change, tendinopathy, right? And it is often intermixed with S1 nerve root problems. So you've all had runners come in and say, I pulled my hamstring. And I say to them, when did it happen? Well, there was no incident. Well, then they didn't pull their hamstring. If there was no bruising, if there was no injury, if there was no event, it's not a muscle injury, by and large. What it probably is is a degenerative process that's happened over weeks, months, or years. And in case of this slide, years, right? So what are we looking at here? Here's the issue of tuberosity. This is the common hamstring origin. That's not normal. That looks like somebody threw a hand grenade at it. And this is what it looks like in a longitudinal axis. So we've got this dark, thickened area here. This is the conjoined tendon and the semimembranosus, which is the most common of the three muscles that's affected, the semimembranosus, for whatever reason. It's the most often that you'll see these changes in. And it can get to the point where it looks like this. This is really severe. And you can basically say it's got tearing in it. It's not torn off the bone, but it's pretty damaged. You'll see variations on this theme. In fact, I think my next slide shows that. Now, this is a more subtle version of that. In this case, you see the semitendinosus on the left and the semitendinosus on the right, and you can see that there's a subtle difference in the way they show up. And in this view, we've got a cross-section, and you can see the subtle change in echo texture here where it's gotten darkened. So that's a tear of a degree. It's not a catastrophic tear, but... And you won't often see hamstrings detached from the tuberosity. You'll see more of interstitial tears. Sometimes I've seen conjoined tendon tears, which are usually attached to a specific event where they can actually sort of... The conjoined tendon unzips, if you will, right? It doesn't transect. It pulls apart. And the muscle bellies are actually intact, but the conjoined tendon is damaged. Okay, more on the posterior hip. This is a little bit more graphic. This is actually a little further down. This is a semitendinosus. On the bottom is normal. On the top of the same muscle, this is the same person, is a grossly transected semitendinosus. It's actually a longitudinal view, just like this. It's just that this, which now looks like a cross-section, are those longitudinal fibers pulled back or retracted. And this is just junk, right? So normally, these fibers would be extending this way as they do in this image. But that's a transection. That's a full-thickness semitendinosus tear. And it's one muscle of the three. It's not all three. So you do have to make that discernment. Another example of the same sort of thing, a little bit more, well, slightly more subtle and cross-section. Here's the bicep femoris. Here's the bicep femoris as well. You can see the obvious visual difference, right? A lot more hypo-echoity, a loss of echo texture and structure. So this is another relatively high-grade tear, probably grade 2. And then this is, of course, normal. So ultrasound helps me grade the degree of injury. Now, again, these are going to be accompanied by some event, right? Person comes in, this happened, now I feel this. It's not mysterious. There's an event attached to it. Now the medial hip, not a common source of running injuries. It's a common injury in people that do some running, particularly things like lacrosse or soccer or anything that involves a lot of lateral movement, kicking. This is adductor tendinopathy, athletic pubalgia, whatever you want to call it. There's a variety here of things that can happen. In this case, we're looking at the adductors, both of them in cross-section. And a couple things stand out, just as I showed you with the gluteal tendinopathy. You've got thickening of the tendon. You've got cortical irregularity and hypoecoity. That's all abnormal. And it's on both sides. I don't think I've ever seen this in a runner, per se. I've seen it in people who run as part of their sport. But it is something to be aware of. Just keep in context to the task that they're doing. Now in kids, it's a whole different ballgame. I've seen a rash of this in the last couple of years, is apophyseal changes. The weak link in kids is where the muscle attaches to the bone, and specifically the bone. Because that growth plate or that growth center is still open, and it's the source of injury or the location of injury. So they present with similar symptoms as an older runner might, but it's a different entity. And so ultrasound comes in very handy here. Now you can also have somebody come in and say, well, I felt a pop and I couldn't run for a bit. That's a little bit more gross. It might actually be an avulsion. But more often than not, it's an apophysitis. And these will respond if you do nothing, because kids will eventually heal. But usually rest is important. Occasionally if there's a pressing need, which to me is almost never, but some parents and some kids are a little bit more anxious about getting back to running. I might do something, some modality. I've had some success with shockwave over that area. Certainly rest, but in a gradual reintegration of running. Getting them in the water is a useful thing, because it reduces some of the traction effect. But apophyseal injuries can happen any number of places in the pelvis, and anywhere in the growing body, the knee, the ankle, of course. So think about it, when a kid comes into the office with somewhat insidious pain, particularly if it localizes on exam to a very tender area, as it often will. Okay, moving down to the knee, the patellar tendon. The patellar tendon is often a jumping injury, but I have seen it in runners. And the classic presentation, oops, sorry, is this. Did I go too far? Yes, I did. Okay, so in this case, we've got the patellar tendon, and at the very top in the inferior proximal portion, you'll get this increased area of hypoacoide. It's almost always inferior, not superior, or posterior rather than anterior. And it looks like this, almost always. Now in cross-section, on the other hand, you'll see this. You see a nice, dense tendon in this area, relatively small area of hypoacoide. It can be worse than this, and it can light up too on Doppler. That'll indicate severity, and that'll indicate to you some degree of prognosis, although I have pretty good success treating this with Shockwave, and it calms down relatively quickly. They still have to go through rehab, and they still have to get strong again, but it's a way to get them to be less painful, because it is a functionally painful condition. The iliotibial band, this is where you're typically going to see it, at the knee, right? And now, often it's not, doesn't have a visual component to it. In this case, I'm showing you a couple instances of fluid collection underneath the iliotibial band, which might be a result of friction, might actually be palpable. But more times than not, iliotibial band is painful, and it's painful because of the mechanics, right? What are they doing at the hip that allows them to have this friction develop at the knee? So if you think about it, if they've got coronal plane weakness, and they're tilting to the opposite side, and now they've increased the tension on the ipsilateral side from above, and they've got now this increased pressure at the lateral knee that shows up most when they're in stance phase, and they're moving from initial weight bearing to terminal weight bearing. And so they feel this pain, this sharp pain that can get very debilitating. You may not see anything. So again, getting back to the point of thinking about it functionally, what's happening? What are they doing above and below? They could be an excessive pronator, or an uncompensated pronator, and put themselves in the same position. So you can't just look at the knee here and say, oh, I figured it out. One, you may not see much unexamined tendon tenderness. When you do the ultrasound, you may not see much either. So what the hell's happening? You got to, again, think beyond the site. Here's another bursitis, right? Pes anserine bursitis, commonly called, this is unusual, but it's there sometimes. And it's often, if you encounter tenderness here, which is almost everybody all the time, but in a pathologic situation, it's often the tendons or the distal portions of the tendons that are getting irritated. It's not so much about fluid collection or a bursa. That may show up, but it's not the primary diagnosis most times. The other thing this can be is a meniscal cyst gone crazy, or even a Baker's cyst gone crazy, where it kind of migrates around to the medial side. I've seen that before. That's going to happen more in an older degenerative condition, or somebody that's had knee problems that gets this crazy-sized Baker's cyst, which technically should be a popliteal cyst. Now this condition can be a little bit more dramatic, a ruptured popliteal cyst, right? It's going to present kind of like a DVT. They're going to have superficial tenderness. They may actually have some erythema. It'll track down the whole calf. You might think of DVT. You might think of cellulitis. It looks like cellulitis. The difference is it will kind of resolve itself in a week or two. But it is a thing, right? How would you treat this? Well, you basically, symptomatically, the cyst is draining itself, so you don't really have to do anything. But it's a condition that happens, and it's usually going to be accompanied by degenerative change. Okay. I'm going to speed up a little bit, because I'm getting blinked at here. Another condition in the leg is a gastrocnemius tear. And in this case, I'm sorry, this is proximal. So this is proximal hamstring tendinopathy. You can see here the semimembranosus with a ring of fluid around it. It's a little thick. And here you see it at the attachment to the posterior tibia. Again, it's thick. It's a little darker than it should be. It's a distal tendinopathy. Tennis leg, medial gastroc tear, they look like this, right? You get this initial tearing at the aponeurosis. This is what it looks like in short axis. This is what it can end up being. You get a seroma that forms that may or may not be symptomatic. But it can be. One, it takes up space. Two, it interferes with the actual function of those two muscles. And it can extend quite proximal, even though that tear was distal. I've seen this a few times. And it may persist for months, years, and it may be a significant finding or not. Moving down to the ankle, a rare sprain. But be aware, a deltoid ligament sprain can show up if there's an unusual foot placement on an uneven path. You can get the talocalcaneal portion of the deltoid can sprain. And you can see the loss of echo texture here in this ligament. More likely, though, you're going to see, well, let me focus a little bit more on medial stuff. This is posterior tibialis tendinopathy. There's a nice, normal-looking posterior tibialis. It widens as it gets to its navicular insertion. But then here's a very chronic, thinned out, and almost ruptured posterior tibialis. This is proximal. This is distal. This is bad things happening right there. And you can see some bony changes, too. So this has been an evolution. It won't often look that severe, but it can. And typically, what you're going to see is more of an enlargement of the tendon. This is FHL, right? So this is an enlarged musculotendinous junction. Here's another distal representation of the FHL tendon. Same thing can happen with the tibialis posterior. It gets thick. It looks kind of large, definitely larger than it should be, and painful because of the stress placed on it repetitively. Here's an example of that. So tibialis posterior, way too dark, way too thick as we look at it here in cross-section comparing to the other side. Much larger than it should be, and it's got a mixed echoity, both bright and dark. So that's typical posterior tendinopathy. And here's another representation of that with Doppler. Okay, so now the lateral ankle sprains here are not unusual, but so is fibularis or peroneal tendinopathy. In this image here, you see the peroneals, and then underneath, I've represented the calcaneal fibular ligament and the talofibular ligament. So those are the common sites of lateral ankle sprain, and that can happen to one degree or another. Most often, it's a grade one or two, and don't forget to look at the calcaneal fibular ligament because that can be something that sneaks up on you. And in this case, now this is a couple of dynamic views of the fibularis tendons where you're going to see, in this case, a split tear develop in the tendon as it moves into inversion and eversion. And this is a snapping tendon right there, bang. So that's a snapping fibularis tendon. That can happen as a kind of a chronic injury that becomes painful over time. Or in this case, here's an extended field of view video of the peroneus longus and brevis. Oops, I need to get that. Is that going to... Here we go, on one side. This is where the split tear will show up, right where those arrows are as it goes into inversion and eversion, you see that dark area develop. And I wanted to go back to this one, and I guess it's not going to show. All right, we'll just keep moving. Lastly, the Achilles tendon. Here's a common example of Achilles tendinopathy, typically in the mid-portion of the tendon. And then you see the characteristic elliptical shape, it's enlarged, it's mixed echoity with areas of hypoechoity in it. And then in this slide, here's what it can look like with a rather more obvious interstitial tear. Here's what it looks like in cross-section. These can heal. And we've got several semi-interventional modalities that can really help progress these. This is actually my own tendon. And over the course of six months, this resolved completely. Not so much on my other leg, though. That's why I don't run anymore. Here's insertional tendinopathy. And this can get pretty dramatic looking. And here you see a very nasty looking calcaneus. Interestingly enough, this is asymptomatic in this person. But this part of it is not. So you get a very increased vascular pattern in long and short axis. And with that, you often can get a retrocalcaneal portion, a retrocalcaneobursal portion. And this sometimes can be the real symptom generator in somebody that comes in with tendinopathy that becomes acute. They may have had the tendinopathy for a while, and then suddenly they're getting a lot of pain. So it's very worthwhile to put your Doppler over that bursa. Because in this case, a simple steroid injection might be really helpful. It doesn't negate the fact you've got to work on the tendon. But it may tamp down their symptoms quite well so that you can do the longer term work on the tendon and the insertion. But I think as you all know, insertional tendinopathy is much harder to treat than mid-substance tendinopathy. All right. All right. And this is more retrocalcaneobursitis. And then finally, the paratenon around the tendon. Don't forget about it, right? Because sometimes it'll show up and it's not really the tendon, it's the paratenon. A fairly simple treatment of a very superficial extra tendinous steroid injection. Front of the ankle, not so common. You can get tendon changes, tenosynovitis, sometimes tendinopathy in the front of the ankle. And now stress fractures. So ultrasound in particular is a very nice go-to tool for stress fractures. X-rays are kind of useless in my mind. MRI is great, but it's not point of care and it's expensive. So there are some very simple things you look for in the stress reaction, stress fracture scenario. Here's a nice normal cortex. Here's one where I think you can appreciate the thickening of the cortex, the shadowing underneath, the pericortical edema, and then sometimes a cortical break, right? So I use this very commonly, very early. I don't have to go to MR very often. And in this case, here's a third metatarsal fracture or at least stress reaction. You can see the same things that we saw in the previous slide. The second metatarsal is more common, but don't forget about third and fourth. They can also have the same sorts of things happening. And then lastly, plantar fasciitis, right? It's a very common diagnosis. It can be acute or chronic. In this case, we're looking at the cross section and then the bottom image is a more acute presentation with a ring of edema around it. And again, in this case, let me move on to the next one because this shows you a side to side version where you've got the obvious enlargement here compared to the other side. So ultrasound is very helpful in that regard. You might see it on both sides to a degree, but obviously you pay attention to the symptomatic side at least initially. So I'm going to cut it short there. Although I went over, I'm sorry about that. Sarah? That was fantastic, thank you. We have time for one question here. So this is a question. Do you have suggestions for runners who have to change their shoe brand or style due to college sponsorship and can no longer train or run in their preferred shoe? But it's important to understand what is happening that necessitates that change, I think. Because that will influence, one, what you put them in and the results you get. I don't keep up on all of the different shoes and all the different models like I used to because there's so many more, but I have folks in my circles that do. So close relationships with your running shop owners who really know what's changed and ask that question. What's different about the shoes that they may be required to run in? What's the closest that you can get to so that there's the minimal amount of change? And sometimes you've got to tweak things, adding some things to the insert that's within the shoe, whether heel lifts or Morton's extensions or whatever it might be to help minimize the difference. Here's where a pragmatic approach will address the anxiety they have about something different in their running situation. Runners can be a little bit compulsive, we'll say. So you kind of have to think through it with them. It's like, okay, they don't make that shoe anymore. Let's think about what we can do here. Now in the next session, I'll give you a tip about establishing relationships with a running shoe store where you may actually spend time there and help people understand why their foot needs this shoe versus not. I did that for a long time. So it's a way to give people information beyond just what color shoe should I get. I've also had professional runners that we've been able to make some type of exception for it too. But it's definitely been an issue, especially when they've changed year after year, that they're having to change type of shoe, because the top thing I typically recommend is the shoe should feel comfortable. And if the athlete does not feel comfortable in the shoe, that can be quite upsetting. We need to wrap up here. We're going to just a couple of minutes over. Thank you so much for joining us. Thank you, Dr. Wilder and Dr. Sianca. And if you're interested, we do have a talk at 1045. It's going to be a panel of running medicine experts talking about developing their running medicine clinics.

University of Virginia Runners Clinic

musculoskeletal evaluations

running injuries

Dr. Robert Wilder

transition

culprits and victims

Rungate Evaluations

Dr. Sarah Reiser

foot strike

ultrasound diagnosis

Dr. John Cianca