medicine meeting tonight. Tonight, Dr. Heather Vincent and I are going to be speaking about the new evidence on clinical exam, functional assessment and injury prevention and runners. Essentially what we're going to be going over is how you would approach a runner as they come into your clinic and how we use the basics of our field, which a lot of it is mechanics and understanding kinetic chain to help us figure out why did the runner get injured? And then what can we do to get them back safely and prevent re-injury? I am Kevin Vincent. I'm the chair of physical medicine and rehabilitation at the university of Florida. And I'm also the director of the running medicine clinic, Dr. Heather Vincent, who will follow is the director of the UF sport performance center. So with that, welcome to the community session for running medicine. Disclosures, we're both associate editors for medicine, science and sports and exercise. And Dr. Heather Vincent's research is being supported in part by Lalamond health solutions objectives. So really look at some cases and give some thoughts about how to critically evaluate a runner during this process, and then to provide an update on emerging issues in the field of running to help prepare the community and members who are facing this patient population. If you'd like more information, we do have a book chapter that was edited by Dr. Harast in clinical care of the runner, where we do an article about the evaluation of the injured runner, where much of what we're going to talk about appears in that article. So from a physician's perspective, what we really need to do is listen to the very closely to the patient. If you listen, they're going to tell you what got us to this place. In other words, what got us here, and we're going to delve into that a little bit deeper in a minute, but just remember that taking care of runners is different. It's different than any other group you're going to see, mostly because they're doing one repeated motion thousands of times. During every mile, they're going to do 850 to a thousand footfalls per foot per mile. And that really adds up, particularly if there's a perturbation in training, mechanics, nutrition, and such. Remember that there's also psychological stressors that go with this group. There are in many groups, but just remember runners, they might be using this as their way of compensating for depression, anxiety, stressors that they have. It could be other social pressures from their coach, their parents, their other siblings, peer groups, internal factors such as relative energy deficiency syndrome, body image problems, and identity type issues where they identify as a runner. If you take that away, you're taking away part of their identity. And it can really at times be more of a psychological issue that you have to work the patient through while you're doing the rehabilitative component. And then to help us with the process, we really employ a group type of a dynamic where we're looking at how do we use gait analysis and our physical therapy colleagues, but you're going to need buy-in from their coaches, their athletic trainers, you might nutrition and psychological support. So bringing the entire group together around the runner really helps because you might have a return to run plan and the coach has something different in mind that's faster to get them back for a meet. And then there's the competing you versus the coach, and that can leave the athlete in the middle and lead to quite a bit of strain. So a key point to remember is when you're looking at running related injuries, there are victims and there are culprits. Now the victim is what the injury is. Now it can be the weak link in the chain. It can be the dominant side of the body that's picking up for something at a different site, but we're looking at the injury. It could be a stress fracture, patellofemoral IT band, but look for the culprit. It's the biomechanical or training error that caused the injury and got us to where we are. So remember the idea of victims and culprits. And just because something hurts, that doesn't mean where the problem stems from. It could just be the weak link along that kinetic chain. Okay. So that's something always important to remember and ask the person if they've had injuries on other body parts recently, have they had, they came in with right knee pain, do they have a left foot pain, a left hip pain, something else that hurt preceding it that might've caused a compensatory gait shift. So we look at running injuries. We want to get a detailed history, imaging exam labs, if necessary, lead us hopefully to the correct diagnosis, bring along our different interventions and then follow up to make sure everything's going correct. One thing to remember is once you have a diagnosis and you sent the person to therapy or to work on mechanics, you want to make sure that they're getting better in the, in the trajectory that you would have expected because sometimes your diagnosis sounded right, but there was something else going on and you need to reevaluate and determine. So look at trajectory over what you think is an appropriate amount of time after they start therapy, just to make sure everything's progressing the way that you had expected. Biggest thing when you're looking at runners as a principle of transition. So what has changed? Really delve deep when you're talking to them about have they increased their volume? Have they changed the surface? Have they tried to run faster? Are they training for a race? They never trained for before a distance that they've never tried. So invariably something has changed and sometimes you'll ask them and they'll say nothing, start peeling through the questions might be that they've added hill work because they're going to do a half marathon at a different state where they have hills. Uh, one of our runners recently in Florida came in and told me that his biggest problem was he came to Gainesville, Florida, which is pretty flat and said he couldn't handle the hills because he came from a place that was really pancake flat. Uh, so it was the first time I ever heard somebody telling me that the hills in Gainesville caused their injury. It's usually hill somewhere else. Uh, it could be they abruptly changed their shoes. They got the same model, but it's brand new, not broken in like the other one. And they just put it on and go running. And that changes how your foot is feeling and dissipating force. Uh, again, psychological stressors. We've had people that came in and they've lost their job or they were having marital issues and they use running as a way to compensate. So they'll double their volume in that compensatory type. Uh, so just really delve in about that eight weeks or so, six weeks before the pain started, what really changed? What caused the transition? So we want to also get a very detailed running history. How much do they run? How many days a week? What's the long run? What are they doing? Any variability in it? Are they doing speed work? Are they doing tempo runs? Is it all one consistent run? What's the route? Are they changing anything in the route? Is it trails? Is it treadmill? Are they doing anything from a cross training perspective, especially weight training to work on strength and stability around the hip. We're going to do some site specific tests that hone in on the areas that they think are on. They're causing pain, shoes, biomechanics, and then special tests as needed. But really once you get into the history and you've listened to the story, they're pretty much going to tell you what's going on. And then you're just using some of this to fine tune or to make sure that you've, you've got the narrow down to a couple of the things in your differential things in the physical exam that you want to do as a single leg hop. Now this is good for lower extremity stress fractures. So if they have metatarsal, uh, tibial fibula, you'll see it a little bit with hip as well. Have them hop up and down two or three times and tell you if it hurts when they land fulcrum test off the end of the table, both supine and prone are good for femoral shaft stress fractures. You'll see people try it with the fist under the thigh. You're doing so much compression of soft tissue. You don't really get a good fulcrum bring them out to the end of the table and use the edge of the table as your fulcrum. And that can really make them stand out. Uh, you think that there's swelling, but is it local? Say the knee, if it's local, it could just be infrapatellar. And then you're getting pinching of the infrapatellar or Hoffa's fat pad will cause a little bit of swelling just under that kneecap area, right around the patellar tendon, but doesn't cause the entire joint to swell. So some people might say my knee feels swollen and say, is it physically larger or does it just feel stiff? Or if you notice something larger where the entire knee or just localized, if it's localized around that pad, then they're basically having patella femoral maltracking. Uh, also be careful not to poke point or push just on the patellar tendon because that infrapatellar fat pad is right underneath. And you're pushing on that at the same time, want to get to each side. So you're getting off of the tendon when you're pushing and looking at that swelling point. Noble compression test is great for the distal IT band. A lot of people will do an over test, but in runners, most of their IT band is really down towards the knee and the noble compression test is best for that. And when you're palpating, just remember a couple of things. You want to palpate like you mean it. You're not really there to massage the tissue. You're trying to push into it to see if it elicits pain and outside of heads and spines, people have two of everything else push on both sides and look for asymmetry and just make sure that you push the same amount on each side. So they can't say, well, you pushed harder on one side or the other. So those are some physical exam tips to think about. When we look at mechanics, I like to have everybody get up and walk. So if they're sitting in the chair, get up and walk over to the table, cause you kind of want to see what they look like as they're moving around. You can check leg length, whether it's true or functional, most runners and athletes, it's a functional leg length where they have a muscle imbalance or weakness that caused them to drop a little more at the hip because of gluteus medius weakness. Look at patellar alignment. When the person is looking and standing, look at facing you, make sure their feet are shoulder width apart and their toes pointed straight ahead. If they're standing like that, the patella should be a headlight and pointed straight at you. If they're converging and they're cross-eyed, you've got an internal rotation on those femurs. So some sort of femoral anti-version is occurring. So make sure that it looks like a pair of headlights. Look at their arch. Is it high? Is it low? Are they flat? Are they kind of standing out like a duck? Do they stand pigeon-toed? And then as you have them go through dynamic tests, watch how that foot is interacting with the ground. So we want to see normal inversion when they stand on their toes. I also have them keep their heels flat. Don't let the heels come off the ground, squat down and look at how far down they can go. If they have nice, normal ankle dorsiflexion, they should get down pretty far. If they get stuck because they can't get into dorsiflexion at the ankle, then we already know we've got tightness in that gastroc and soleus complex. It's going to lead to early forefoot loading when they're running, and it's going to lead to more pain and discomfort, usually in that Achilles, but it really can manifest itself through the bottom of the foot and those various arches that we have. You can have them do flexibility, single leg squat, which will go over a second. And again, like I said, watch their gait as they're moving around in the room or even up and down the hallway. Single leg squat is one of the most important things you can do in this population, have them put their hands on their hips, stand on one leg and three times about 30 degrees, kind of quickly up and down, up and down, up and down. So with this, you can see if they're weak here in these abductors, external rotators and gluteus medius, their knee comes in on an angle. So either their pelvis drops or the knee goes in and you make them go up and down. And you'll have some people that they look like they're going to fall over. They can barely stand on one foot and they're falling over and they're wobbling and they'll say, I don't have a good balance. And then you tell them, well, just think about running as a series of single leg squats, because you're going to go about two inches up and down as your oscillation when you're running. So you do 850 to a thousand single leg squats a mile. If they can't do three of them and look stable in clinic, ask them what they think they look like after a thousand or 2000. And then you start to get the idea of this rotation that can be occurring at the knee. And so they can get patella femoral pain and get IT band pain. You can get medial ankle pain because if your knee goes in your ankles going in too. So you see a lot of runners, they're told that they're a pronator or they're over pronating. Well, they're pronating because of weakness at the hip, driving the whole kinetic chain in, not because of a problem at the foot. And that usually is the majority of runners that their pronation is a hip problem, not a foot problem. So you don't need to put them in stability shoes and orthotics, treat the hip, get the knee stable and everything below will be stable as well. Functional. We'll do other things that double leg squat. Like I was mentioning, look at their range of motion. Look at the patellar alignment, single leg stance, single leg squat star excursion test, which is this, which is pretty simple. That's just duct tape on the ground and see how far out they can tap. And as they go around and look at their control, and then you can do a step down test as well. So when we think about it, when we have healthy motion and healthy loading, and there's a biomechanical deficit, we're going to get the pathological motion and loading, which is going to lead to injury. If we do rest plus or minus rehab, but we don't correct the deficits, that's when they get injured again. And then we get into a cycle of they're injured. They do some rehab. They do some rest. Pain is better. They go back to sport. You didn't correct the reason why they came and saw you in the first place. And then they get hurt again and they come back. And this is the cycle that we're in. Now, sometimes it's because you're trying to correct it and they're not listening. Sometimes you can't figure out what the deficit is. You might not have a therapist who understands what you're asking to do in terms of gait mechanics and such. But if you don't correct the deficit or what got you here, and sometimes it's a training deficit as well, that they're over-training or they're not training the correct way, or they're not adding the right stability exercises. You don't correct what got you here. You're going to see them again. And then they become the frequent flyer in this cycle. So biomechanical deficit is an adverse motion or loading pattern that causes inflammation and structural damage to tissue. How do they develop? A whole host of reasons. Extrinsic from training, surface footwear, to intrinsic, all these types of things. You can just have one thing wrong, or you can have a bunch of little things that are adding up to break down the system. And that's where the real fun gets in, is trying to figure out how many of these have. Running experience is a big one that if you were going to chase somebody down the street, they know how to run and get away. But running for exercise is different because of those thousands of loading cycles applied day after day, week after week, month after month, little bit of inexperience with poor strength training, poor slow cadence, poor turnover, all these types of things really start to break down the system. A person that they're highest risk for an injury in the first six months that they start training, and they're usually pretty good about on time. And that first six months you'll see them sometimes faster. We saw a kid today who had been running for all of two weeks and started to have pain already, or they're a stable runner and then they get an injury because something changed. And that's that transition that we're looking for. So what we want to do when we have this cycle is we want to use relative rest rather than an absolute rest. So if you tell a runner to stop running, they're not going to listen to you anymore and you've lost them. So you want to see, well, what can we do? Can we have them run at a sub symptomatic level and let them know that if you run and you're making the pain worse, you're trying, you're making things worse from trying to make them better. We got to pull you back further. Or if I've got to pull you out of running because that's the, really the problem, it's the loading or it's a stress injury. What can I have them do? Non-impact cross training and strength training, things along those lines. So how do I work with the person to sort of keep them active and not lose them unless I absolutely have no other choice. And then I let them know that, but I try to get them active as soon as we can. Looking at their gait, appropriate rehab program. And this is your best friend, the physical therapists who really understand gait, who understand what you're looking for, for dynamic stability, cadence, and turnover, all of that stuff that they're going to be your best friend helping because they have more direct exposure and more time with the patient. So we want to correct the biomechanical or the training deficit, get them back to a healthy motion and loading pattern and get the person back out running as soon as we can. And that's where the rest of the talk will proceed to, but let's talk about a few people. And so what I want you to think about is remember taking care of runners is different. So you don't want to jump to an easy conclusion. What you really want to think about is rule out the worst stuff and be satisfied that it was the easier solution instead of the other way around. And that's what was going to make you different as a specialist that you don't jump to the easy answer. So we had a 17 year old female, and actually these are all going to be people that we see. And so she's complaining of right hip pain three weeks into the season. Trainer told it was hip flexor tendonitis. So what do you want to know? You're going to want to know, well, how much exercise is she doing? Is it running? Is it rowing? Is she doing dry lands? Did she do any pre-season training? Was she doing any strengthening? All the things that we talked about. What was the transition? Because we're three weeks into the season. Did she do any of the pre-season training program? Anything around energy intake? So if she's working out harder now than she was before, but not changing her eating pattern, maybe we have a relative energy deficiency in sport type of issue occurring. So we asked her some questions and she, season started with conditioning, mile run every day, running stadiums, rowing, plyometrics, and sprints. So pain was initially present after practice. And that's an important thing. Ask the person, when did you notice the pain? Was it at the beginning of exercise and then would go away? Was it after exercise and got progressively earlier during exercise? Does it throb or ache at night? So these can delineate. If it's initially cranky and loosens up, that's usually soft tissue. It's pain afterwards and gets more present during exercise, even then at rest, that's usually a stress fracture. Dull ache at night can go with a stress fracture. So those are kind of clues that you're going to pick up in the history. Progressively pain started to occur during exercise. Now it's present with walking. That is the description of a stress fracture, not the description of hip flexor tendonitis. So do you want any imaging? I sure do. So here's our X-ray. So we've got our femoral neck right through here, femur pelvis, and everything looks pretty reasonable. It's nice and normal. And there's our femoral neck stress fracture sitting in right in here. Now, the interesting thing about this girl is her mother's a physical therapist and she's the one who told her she had hip flexor tendonitis and then sent her to me. And what I didn't show you in this is she ended up actually with bilateral femoral neck stress fractures instead of bilateral hip flexor tendonitis, but it was all in the history in the story. So she wasn't doing all that impact. And they started right at the beginning with all this impact. So what happened? Hip flexor, she had hip weakness. She's a rower, not a runner, and she didn't strengthen her hips. So she didn't do the properly prepare for the season. She didn't properly prepare for the conditioning that was coming and she had weak hips. They started running really hard and her hip basically broke down. Case two. Now this is a 28-year-old female. She's run training for a first marathon. So now we know there's our transition point. She's running for a distance she had never run before. She's diagnosed with pes anserine bursitis, sent to therapy, but the pain is getting worse. Now, same thing. How fast was she ramping up? All the questions that we want to ask, but there's something important in the story. It's a 28-year-old runner with pes anserine area pain. When you have a patient who's got, she's a runner or any runner with pes anserine region pain, and here's a sclerotic line that you see with a fracture. It is a stress fracture till you prove it's not. Group of, we looked at 40 consecutive patients with pes anserine pain here, about 80% of those, and we present this at meetings last year, ended up with pes anserine area stress fractures. The majority of those over 70% were grade fours with that fracture line. So just remember pushing on the person and having pain there will make them hop. Does it ache like a toothache? Anything like that. In a runner, pes anserine area pain, it is a stress fracture till you prove it's not because more likely it is because so many people think it's a tendonitis. The majority of the ones that we see end up being grade fours. Interestingly enough, we just had the first negative MRI scan in the last couple of years this past week. So it's every once in a while they're negative, but the overwhelming majority of time they're positive. So just remember that. This is a 15 year old female cross country runner with leg pain. Now, it's in the posterior, and first she thinks it's like just below her knee. So, she actually came in and said, I have knee pain. Now, her trainer and everybody thought that it was calf pain, calf strain, because she's running. But, it's worsening with running, it's present with walking, and it throbs at night like a toothache. She didn't participate in any pre-season training. She was never a runner before, and she decided, I think I'll run cross-country. So, she goes out running. So, we get these x-rays, and you can see this line right here in this left leg. But, take a look here. See how it's posterior? Right about where soleus and other muscles are inserting. These are her MRI scans. So, this is a tough one to recognize, because a lot of people are going to come in and tell you that they have calf pain or a calf strain. And, they're a cross-country runner, which doesn't really go very well, because unless they're doing speed work or sprinting, it's such a low volume or low velocity rhythmic movement. You don't get a lot of calf injuries in regular runners that way, which you'll get are these posterior stress fractures. What makes these really hard is how far this can go across, and you've got to be concerned that you catch that anterior part of the cortex and the posterior. The reason for that is, if it does, it's going to get unstable. You've got to make them non-weight-bearing and really monitor with x-rays every couple weeks, because if it shifts, then you've got to put the nail down that tibia. The only one of these I've ever had shift was a kid who didn't listen to his weight-bearing restriction, and we saw him every two weeks for his x-ray, and I said, as long as you don't see the surgeon, you're in good shape. One day, it came in, and he shifted, because he didn't listen, because the pain had come down. And I said, today you get to meet the surgeon, and that was the only one that went bad, if you monitor this to see that it doesn't get that anterior cortex. Now, you put them in a boot because you have to keep the person from plantar flexing. You've got to take that muscle pull off. It's a little bit longer to heal because of that muscle traction, because remember, anywhere a muscle inserts on a bone, you can get a stress fracture. So, just think about the movement the person's doing. Think about the sport they're doing, and does calf strain make sense, and that progressive worsening and throbbing like a toothache? Not really. So, just remember, rule out the bad stuff first. This wasn't hard because you brought us that x-ray, but even the story would have led you to that conclusion. So, what I want you to think about is look for patterns that fit. Look for masqueraders. Look for things that sound like one versus the other. Compartment syndrome can be a radiculopathy. We had a lady whose husband is a sports medicine surgeon. He sent her to me for lateral compartment syndrome. Honestly, it sounded more like a perineal neuropathy. We did an EMG, and she actually had an L4 radiculopathy. Plantar fasciitis, person was battling her plantar fasciitis for two years, was not getting better at an outside therapy. Listen to the story about what she was trying or what she was doing. She ended up being an S1 radiculopathy. We've also seen people with plantar fasciitis not be a plantar fascia problem, but be a stress fracture. Now, you can get a calcaneal stress fracture because not all heel plate is plantar fasciitis, but remember this. Like I said, anywhere a muscle inserts on a bone, you can get a stress fracture. So, there are four layers of muscle on the plantar side of your foot, all inserting in the calcaneus right where the plantar fascia inserts as well. If they have a lot of stiffness, they're not very flexible, they have problems with their foot musculature, and they're overloading it, it's pulling on the bone, the bone can break down. So, if you've got a person with plantar fasciitis, and it just doesn't seem to get better, it just doesn't sound right, MRI it, you'll probably find that they have a stress fracture at the muscle insertion site on the calcaneus. Persistent postpartum hip pain. So, your patient gives birth, she wants to get back out and exercise, she has persistent pain. There's some articles showing that persistent postpartum hip pain can be a labral tear and labral pathology, so that's something to keep in mind and look for. Not just everything sort of stretching and spreading apart. If it's persistent, consider that there's a labral tear. Patellofemoral pain is interesting, because it's the most common reason that people come in to see us, but we've had other. We've had one person who came in with, for all the world, looked like patellofemoral pain, even went to therapy and got better with their patellofemoral pain, never said anything about hip pain, came back with worsening pain, scanned his knee, nothing, x-rayed his hip, had a SCIFI. It's like one in every 1.5 million SCIFIs present just as patellofemoral or anterior knee pain, and we happened to get them. The other thing you'll see are saphenous nerve entrapments, so remember around Hunter's Canal where that nerve comes out? If there's an entrapment there, it can give you an anterior knee pain that looks a lot like patellofemoral. We even had one kid, came up from Miami. He had battled his patellofemoral pain for so long. They did diagnostic arthroscopy on an 18-year-old, VSCO supplementation, steroid injections, physical therapy, bracing, couldn't make it better. We retried some of the therapy, couldn't make him better, injected his hip to see if it was referred from the hip. Turned out he had a congenital abnormality around his spine that was pressing on the L4 nerve. We decompressed that, and his patellofemoral pain went away. So that's what I meant about follow people up and see, does it get better like I would expect? Dorsal foot pain, I'm still waiting for the person to come in here where dorsal foot pain is not them tying their shoes too tight and compressing those anterior structures. We'll also get dorsal foot pain from people wearing shoes that are too small, and they cinch it up really tight. So first thing you want to do is open up the top of the shoe a little bit and see if that makes their dorsal foot pain go away. We've got a good story about that. We can do it another time. Thigh pain in a runner. This is an important one. So I'll give you an example. We had a young lady come in months ago. So she had been told that she had a hamstring strain, and she's a just cross-country runner not doing any speed work. Well, that really doesn't happen unless you do speed work. You're not going to get a hamstring strain. And then they told her she was having some quad muscle problem, but she didn't have that either, but she was getting worse. She was having pain at night, basically did an MRI, and she had a femoral shaft stress fracture. Think about the population. Runner with thigh pain, it's usually that distal half. So it's not where you see the femoral neck. It's that distal half of the thigh. It aches and it throbs. It's getting worse while they're running. You wish it would hurt more, but sadly it doesn't. But a cross-country runner isn't going to get a thigh, a quad strain, not going to get a hamstring strain unless they're doing speed work, and she wasn't. First thing you got to think about, femoral shaft stress fracture. Put them on the fulcrum, prone, and supine. Do them both ways on both legs. And if there's asymmetry, get the MRI scan and get their weight off of that thigh. The other one that will get you is, and I've seen it more in runners that are over 50, but they have a thigh pain and it's posterior, not right where the ischial bursa is or the ischial tuberosity is. A little bit further down in the posterior and it's right around the gluteal insertions. And they'll get a posterior femoral shaft stress fracture and they'll tell you it hurts when I sit on it, but you palpate that ischial tuberosity and you're like, it's not there, it's lower. It's more distal. And you'll find that they'll have a posterior and those are tough because you've got to change the muscle pulling on that shaft. So just remember, thigh pain in a runner, more likely, if they're not a sprinter, to be a femoral shaft stress fracture than it is a muscle injury. So make sure you're working that up. And I'd rather work it up and be wrong than have a catastrophic failure in a femur. And they're not going to be a runner anymore if we miss that one. And then the persistent calf pain, like the one that we just went over, persistent calf pain in a runner, we're thinking about that posterior stress fracture because that's one that can hide in the background. And so those are things where you're looking, does this pattern fit? Does it go with the type of a sport or exercise this person is doing? So in summary, think about running specific history. Look for that transition. If they say didn't make one, then keep digging because invariably it's in there somewhere. Think about how all the parts work together. Just because they point at a body part, it doesn't mean that's the problem. That's the part that broke down. But where is the problem stemming from? Think a lot about functional stability. Think that you're in the air and you're going to land on one foot. And it's a combination of you've got to decrease the force they produce when they land and improve their body's ability to absorb force by changing their gait, changing their stability, and changing their strength. So think about those things as well. With that, I am going to hand this over to Dr. Heather. So pardon us for a second while we switch places. Hi, everyone. Thank you so much for tuning in. Before we go on to the next section, it looks like there were a couple of things that came up in the chat. I'm going to see here if maybe Dr. Kevin can answer some of these for you. Dr. Kevin, are you online yet? I am. Okay. Can you see the chat questions? Let's see. I've got, how long did you wait to get the MRI after the X-ray was negative? No time at all. The thing to remember is that the majority of stress fractures never show up on an X-ray. Greater than 70% don't. Clinical suspicion trumps a normal X-ray. So if somebody gets a normal X-ray and says, oh, they told me I didn't have a stress fracture, they don't know what they're talking about. So what you want to do is if you think you've got a runner and the idea of femoral neck stress fracture dances through your head, you get the MRI scan right away because that's the most catastrophic of all the failures that we can have is that femoral neck stress fracture. So if I remember correctly, case number one was the swimmer with the femoral neck. I get those right away. I generally want them completed within three days. If they have any pain with walking, I put them on crutches for protected weight bearing right away. Typically they're only one side. It's a little bit more difficult when they give you bilaterals, which does happen. So I get those right away. How often am I diagnosing these on MRI? I guess I just answered that. The overwhelming majority are on MRI or clinical suspicion. There are times like with a tibia where you've just seen them so many times that they come in with the right pain. It hurts when you push on it. It hurts when they hop on it. I don't need an MRI scan to diagnose it. I can just tell them this is what it is. Sometimes they want the MRI just to prove it or they want to see how bad it is. Metatarsals can be a little bit that way. Sometimes you'll see some periosteal reaction. But for the most part, you're diagnosing really on an MRI scan. The reason to get an X-ray is every once in a while you'll see it like that tibia. But in our area, the majority of the insurance carriers make me get an X-ray before I can have the MRI scan. So it ends up being a little bit of a formality. And we have a second question here. Bless you. Thank you. Is there a golden ratio? Not really. So when you're looking at the ratio, you want it to be a little bit sport-specific. You'll have runners that run a two-mile race and they're making them run 50 miles a week, which is really overtraining when they could do better quality training by bringing the miles down and have some of them be distance and some of them be speed. But what you want to do is make it appropriate for the type of a race that you're running. So think a little bit about some overlap training for base type of cardiorespiratory endurance and power. But you want to get the energy systems ready for the actual activity the person's going to do. So there's really no golden ratio other than be specific and really targeted around the event, the length of the event, and the type of energy systems that you're going to use. So I don't think there's a golden ratio. It's just going to be different based on the event that you're looking at. And how do you get those energy systems ready? But then remember, a lot of it is getting people ramped up at a slow enough pace so that they can adapt. The sprints, the issue with sprinting is it's such a high-velocity movement. You'll see people, they look really good when they're running at a distance sort of a pace. And then you make them sprint and their form, and Dr. Heather sees this all the time, falls to garbage because they'll just make these really long stride lengths. Instead of raising their foot up a little bit into more flexion, where they're going to change their flight time more so than that just actual stride length, that's what's going to get them in trouble. So they change all the forces in the loading. And so when you're doing sprinting, not only do you have to ramp it up slowly, you've got to actually make sure that their form isn't falling apart at the same time. So I don't know if I answered the question directly. Other than I don't think that there's a golden ratio more being sports specific or event specific that you're training for. With that, I will hand it over to Dr. Heather. Thank you. Thank you for the questions. What I'd like to do is take this next part of the talk and bear with me with my voice. I promise I will get through it. What I'd like to do is take this next period of time with you and share with you basically years of research, years of work that we've done with these patients and clients and what we've learned from it so that we can share our experience with you. One of the areas of expertise that I have down in the Sports Performance Center is doing 3D gait analyses in runners. And these are particularly useful under certain conditions. So first, if you suspect that there might be mechanical mechanisms that are one of the culprits that we talked about a little bit earlier in the talk, this is a good way to really look at that up close. If we find, for example, that someone has a wandering musculoskeletal pain or recurrent injury that is not getting better, this is also another way that we can look to see what is going on at a deeper level. If, for example, plans of care aren't working and the injury continues to worsen, we add the 3D analysis in to see what we can figure out. If we also determine that through the history taking that at a consistent running volume that there's a threshold of distance or duration at which there appears to be pain onset, this could be a clue that there's something mechanical going on and we can take a look at what that is. There could be potential disjunction about perceived motion and actual motion. So if through history taking you find out that the runner thinks that they're more of a mid to forefoot striker when in fact you suspect they aren't by looking at the bottom of their shoes, part of what we can do is ascertain for them what it is they're actually doing and give them an inside view. We can also rule out mechanical mechanisms. So if we find that with this recurrent injury, if it's not mechanical, then we look at another pathway, whether it's endocrine or otherwise. We can also use 3D analysis as part of tracking progress during follow-up over the course of rehabilitation, but also we can see what's happening or going on at a phase in which there might be pathological or compensatory gait that can happen after an injury. So 3D gait analysis are very useful in all of these situations. Most importantly, it tells us a story. And in every single analysis that we do, I take the data and find the story. So over the years, what we've learned is that we can talk about data from a really high 10,000-foot view or we can get extremely detailed. And really the Goldilocks zone is somewhere in the middle. Often runners like to know just enough where they understand the mechanisms, but then also the data that we produce can give them targets that they can shoot for as part of their retraining. So this is a sample of a first page of our 3D analysis that we provide to our patients. And the first page are our temporal spatial parameters. We put these right up front because they are high-impact, high-efficiency methods of being able to change gait parameters and are excellent for cueing. The second page includes ground reaction forces and impact loading. And because we look at symmetry and symmetry is critical as part of our analysis, we present both the left foot and the right foot and compare our ground reaction force curves vertically. So what we're seeing here is the vertical up and down, but then we also look at the side-to-side force. So if we suspect that there's a force pattern that's contributing to a bony injury or recurrent soft tissue injury, we can also take a look at where these forces are being applied. Down in the corner, you see here in this right-hand corner, we can also take a look at leg lengths. Now, this is not necessarily anatomical leg length. All we know is that based on the ASIS position to the malleoli, what is the leg length? So because we don't have the EOS machine to look at actual full-scale bony differences, all we can tell the runner at this point is if we are seeing a functional leg length difference here, which is also very critical. The third page of our report, we use as a snapshot to talk about all the motion that happens from our three points of view. So what this picture is showing us here is the sagittal or side view. The middle column shows us the frontal view of motion. And then the right panel shows us the transverse or top-down. What runners really appreciate about this, whether they're young or old, is that they can see their own motion, which are the colored lines. So the right side is a red line. The left side is green. The gray bar represents the average expected performance from other healthy, non-injured runners with beautiful running form. We also have been very fortunate over the years now to have collected thousands of runners' worth of data. And so we apply a really good, quote, comparative or a normative standard here so we can take a look and see how are each of these patients or clients comparing to themselves and to others who do not have injury. So it's a really neat way of doing a snapshot and doing a scan to find where are they differing far from themselves, right and left side, for their ankle, knee, hip, and pelvis, and how their motion compares to others. So it's a great way to kind of walk them through from start to finish what's going on. And I look for the story. We combine the temporal-spatial, the motion, and the force, and we find what could be possibly contributing to this person's experience. We also age-adjust these and foot strike-adjust these. It doesn't make any sense to compare an 18-year-old heel striker to a 50-year-old mid-foot striker. So we have them separated by sex, age, and foot strike type. So they really are apples to apples comparisons. In order to get a really good analysis, there are standards that we've published over the years to kind of show if we really want to tell a top-notch story, this is the typical setup that you might see. So this is an instrumented treadmill over here on the left with a minimum camera setup of seven cameras. We couple that with the high-speed camera, which we've dubbed in the middle here, little Vin, for little Vincent, after Dr. Kevin. So this is high-speed film between 300 and 500 frames a second that gives us some nice high-quality capture that we can replay in real time for the patient and their family. And then this is just looking over the shoulder of our engineer to kind of see what it is that we're looking at here with our report, the camera view, and our modeling that we do to create this report. What we care most about, and we continue to learn and build up our evidence, are the key outcomes which include, in the temporal-spatial domain, cadence, step lengths, and symmetry. We also look at stride width, and that represents an idea of whether or not a person is crossing over their footfalls rather than keeping feet parallel. We look at stance time, or percent of the gait cycle, and we also look at the vertical displacement of our center of gravity. How much are they bouncing? And over the years, we've published a number of clinical pearls on this information, what we've learned, and how it relates to injury. So if you get the chance, feel free to take a look at what we've learned in the literature. And we also then apply this going forward to some kinetic measurements, including our peak ground reaction force, our impact loading rate, and then also the impulse. So what is that area under that ground reaction force curve? So some of those patterns are really informative about how a person is interacting with the ground and how it can relate to injury. From the kinematic point of view, we look at the joint excursions and the three planes of motion, and we also add to that, from the video perspective, our shoulder-to-pelvis crossover and whether or not that's symmetrical over that center of gravity. We also take a look at the ankle angle at foot contact to determine just how dorsiflexed a person is. And then finally, anterior pelvic tilt. So these have come to be very indicative of some of the stories that we find underlying our key injuries. Finally, and importantly, we look at symmetry and how well a person can control each gait cycle and consistency between gait cycles. And that is crucial for thinking about robotic motion over an endurance run. Once we have that information, we determine the problem areas. For example, excessive loading with the time or force applied, the asymmetries in motion between right and left or among the gait cycles. And then what's also coming to fruition here as a really important indicator is how much motion is there away from our center of gravity? And what we've noticed in particular, especially with the upper body, if a person is driving using their arms in a way that involves a lot of rotation, it pulls the person's body away from that center of gravity, which means the lower body is fighting itself to keep the person moving in a straight line. So there's certain problem areas that we keep an eye out for as part of the story. So I'd like to share a few sample patient cases here with actual motion analyses. So this one here is a high school, I'm going to move this bar off to the side here, it's a high school competitive runner who's had a recent growth spurt, oops, I'm sorry, something just happened with my sharing, hang on. Okay. This is a 15 year old male, 65 kilograms tall and lanky freshman on a varsity cross country team. As a freshman, he's already running more than 40 miles a week, and he's trying to keep up with the older boys. At this point, as a young, as a young individual on the team, he's not really engaged in any other type of training, nor is he engaged in strength training. So that's part of this history taking that we're doing here. Symptoms, none at the present time, but the father wanted to be sure that they could prevent injury by reviewing the form. And he was a little bit concerned because he just felt that the running form was off. Something didn't look quite right. The father also reported in response to my questions about growth spurts. So growth spurts are another reason why we might have a rapid onset of injury. Typically between the ages of 14 and 15 years, we start to see a higher incidence of injuries in our, in our runners. So looking at the temporal spatial parameters, the first thing we notice is the cadence is 159 steps a minute, and that's a left, right, left, right. Temporal displacement is about 11.6 centimeters. When the comparison for his age group of boys like him is about 8.1. So it's about 30, 35% higher. And the steps like step lengths are huge. It's about 1.2 meters for every step. Stride width is about seven centimeters, which is very narrow in comparative terms. The stance time left and right is a little bit uneven. So there's some discrepancy here between 43% and 45%. Now just to give us a little bit of context, what we try and encourage people to do is lift their feet very quickly up off the ground. The longer the stance time, the greater the likelihood is they're going to put more stress on their joints and their soft tissues and longer stance time is associated with a greater risk of injury. So when we look at what an optimal is, we really don't have an optimal. There has not been one identified yet for running, but the closer we can get it to between 40 and 43%, the better. So the person's natural running speed here is about 7.6 miles an hour. Here the cadence is problematic. So for this young man, this is tending to be on the low side. I do want to let you know that there is no such thing as an ideal cadence. There is no one set cadence that's appropriate for all runners. This is entirely dependent on the person's height and the mechanics at which look optimal at a specific cadence. And what I mean by this is that for this tall, lanky person, probably increasing that cadence to somewhere between 165 and 170 is going to take us to the mechanics where we need to be. The center of gravity vertical displacement is too high. We've got excessive bounce and our step lengths are long. So this can also contribute then to a long narrow step, which likely means the feet are crossing in front of the person's center of gravity. So we have some problem areas here. These particular responses are what we want to take a look at as part of this story. So we need to pick up the feet a little faster, have faster turnover, and shorten up the steps quite a bit. So I want to share with you a couple of videos of what this young man looked like. And so just from the side view here on the left panel, we see he's really getting a big vertical bounce, big airtime. And when he brings his feet into the ground, he's jamming his heel into the ground, definite heel striker. But when he lands, we don't have a lot of flexion at the knee either. And there's a huge propulsion of the foot as it stays behind him, a big push off at the ankle. If we look at the posterior view here, the first thing we notice is that you can see the feet are landing right in front of the center of gravity. So big crossover. And also when he lands, watch the pelvic drop. So this means we don't have a lot of control over the motion. And also if you look at the spine and the lateral tilt, we do not have a lot of central control going on here with each of these footfalls. So if you can imagine that this is the best that this young man is going to look without fatigue, you can probably imagine after running a few miles that this is completely exaggerated with even more crossover, more pelvic drop, and a lot of truncal swing and lateral motion. So what are his impact loading looking like in his ground reaction responses? Well, what I have here is a panel view where we're looking at the force here in Newtons. And this is a sample of the left foot footfall and the right foot. So what we're seeing here is the initial foot contact, weight acceptance, and this huge spike right there is indicative of the heel plant into the ground out in front of his center of gravity or in front of his hips. So he's definitely striking out a bit too far. And what that corresponds to, if you look at the blue table over here as approximately 2.5 body weights, when we look at our peaks, now the peaks are identical, which is good. If we come over further on the chart here and we compare him to his peers, these are tending to be higher forces. I'm not as concerned about this as I am with the next part of this graph. And what this is showing us right here is this first part of the curve from foot contact to the top of this initial spike. Those are the impact loading rates. This tells us whether or not a person is cushioning the blow when they strike the ground. This usually resonates very well with our runners and the family members who are looking on as we tell this story. So if we look at the left impact loading rate and the right, we go across here and we look at body weights, 83 body weights on the left and almost 75 body weights on the right. A little bit of difference here. So a little bit of asymmetric loading, but look at how huge this is. A hundred percent would mean they are slamming into the ground. There's no control with a rigid, uh, with a rigid slam into the ground and no cushioning. So these are very big problem areas. In addition, if we look at the side to side force, it's very wobbly. And this goes back to the concept of control. If a person is not controlled when they land the leg into that single leg, that single S uh, single legged squat motion, you're going to see wobble that looks like this. Get my cursor. So if you can see where my cursor is going, this wobble is what would show up if we do not have control in our single legged position. These are our problem areas, high impact loading, foot slamming into the ground. So now if we look at our overview here of our motion, what I try and get a feel for as I scan this whole picture, I scan all of this to find where there could be potential areas of problem. So if I look at our side view on our left panel right here, one thing that jumps out is that you can see when he brings his foot feet into the ground, this is the initial part of the gait cycle, foot contact, mid stance, push off followed by swing phase. So the first 43 to 45% of each of these pictures are when the foot is on the ground. The remainder is when the foot is in swing and in the air, I really care most about that first 43 to 45% when the foot is on the ground. This is when the person is experiencing the forces and the impact. So when this runner brings their feet into the ground, you can see that their toes are up significantly more than their peers, even for heel strikers. So this is a huge drive into the ground. What I do like is that he's pretty symmetrical motion wise between the right and the left, at least from the side view, hip motion looks good, knee motion looks good. He's got a lot of knee motion to clear the ground, which I like, that's not a problem. But if we look at the pelvis first, can you see how much wobble there is? Now this represents the forward tilt of the pelvis. We fully expect that runners are going to have a little bit of rocking motion. That's normal, but his is extensive, very dramatic rocking back and forth. That also indicates a lack of control, especially in the truncal and core area. But also the position of his pelvis is tucked back a little bit. So not only are we not controlling it, we're settled back a little more, which could also potentially lead to hamstring problems and to low back pain. So I think this was probably one of the biggest gifts that this father could do was bring this young man in and catch these problems now so we can therapize them and prevent injuries from happening. If we look from the front view, there's a little bit of asymmetry. If we look at the foot position in terms of pronation, supination, eversion, inversion, but most of the weirdness is happening after foot push-off as the foot is swinging up into the air. Those things are going to correct once we get control of the cadence and allow the trunk to start being stronger. If we look at the knee forces here, this is the only exception to the rule where we don't plot motion because it's such a small amount of motion from this point of view, it doesn't add much to the story. So we plot the varus moment, which is that tendency to have a twisting force on the knee and knees don't want to be twisted. So here the forces are actually pretty low, which is good. If we look at hip motion, this picture actually represents a little bit more of the pelvic drop and hip motion together. And surprisingly, it looks pretty good right now. Pelvis motion also doesn't look too bad from this point of view. If we look top down in this last panel on the right, again, not too bad. A little bit of variations here when we look at foot position. Most of this is driven, especially on the left side, because he's really swinging those feet around and crossing over. The computer is sensing that the toes are in. It's really not the toes that are in, it's the whole leg. So part of what we need to work on is fixing that crossover and that will adjust. If we look at our thighs rotating in, we know that the femurs don't just move back and forth. They also rotate in and out in the hip. Looks pretty symmetrical to me. And then finally looking at the pelvis motion, ever so slightly, the right side of the pelvis is driving just a little bit more forward than the left. So when we put all this together, what's problematic on this page, the foot drive in with the toes way up, oops, foot with the toes way up here. And so how do we take this information then and how do we prevent injury from happening? Overall, what this young man is suffering from is lack of muscle strength. At this point, since he's not doing any other training, not engaged in strengthening exercise, aggressive therapy is going to be the first place that we start. So these are going to include barbell exercise, free weights, kettlebells, and we have a whole rehabilitation protocol at the University of Florida that once they're rehabilitated, it's a maintenance program, which involves heavy exercise that you see here. In addition, motion control is also going to be very important for this young man. Working more on lunges, single leg, even half squats and developing the neuromotor control is going to be critical. Developing strength in the core. So not just the glutes, not just the hips, it's an overall axis of control along that spine to prevent that lateral trunk tilt. If possible, we want to go barefoot doing some of these neuromotor control exercises and lunges and squats. And then finally, when we look at the changes in the form of the running, there's going to be a couple of things we need to master right away. First, we need to improve the foot turnover. That is going to be critical. And I guarantee with faster foot turnover, we start to see a softer football, more cushioning. And then also the other technique and cueing that we've used over the years that's very successful is squeezing the buttock muscles together. It's hard to run badly when you've got abdominal tone and your buttock muscles are squeezed because everything becomes tightened up, aligned, and the feet also no longer are crossing over. They become parallel. So if there are hard hitting clinical pearls, I could leave you with this. It would be those faster foot turnover, soft, quiet footfalls, and make sure we activate those muscles that should be activated. And with a good therapist working with the runner, all of this can be accomplished. The long-term goals that we want to set for this individual to prevent injury from happening is to avoid running long distances and running long distances in particular with the runners who are much more mature or older and who are more experienced. Pulling back on the sum of the volume and substituting some of that volume with the therapy and strengthening is going to be critical for this young man. And then once we have control over the running and he develops his musculoskeletal system more, that's when we can have slow evolution, some of that volume. Okay. If there's any questions, feel free to put them in the chat. I'm happy to take a look at those as well. The second case is a runner with recurrent knee pain. She is age 31 years and she's actually a very fit individual. She has a BMI of 28, so that falls into the overweight category, but this is a little bit misleading because she's actually very active with several different sports. She was formerly a high school runner, but she had frequent issues even when she was in high school and it was always knee pain, always knee pain. Now she has continued to stick with her horseback riding that she did when she was young. As a young adult, she actively does that multiple times a week. She's actually a yoga instructor. She plays pickup soccer and she does aggressive strength training for three hours a week. So she's very active, very muscular. So the BMI is in part due to a lot more musculature. The symptom that she's dealing with is recurrent lateral knee pain. That's it's disruptive to her running. It's seven out of 10 pain and appears rapidly every time she runs. So this is after 10 minutes. She has a history of repeated right tibial stress fractures. She's given up on the idea of running for endurance, and now she considers herself more of an interval runner because she just can't run. It's too painful. In her quotes, she's quote, tried therapy over the last couple of years, didn't work well. And then unfortunately COVID set in. So she was, she was unable to do what she needed to do with aggressive therapy, but she still doesn't want to give up on running yet. So in desperation, she came and did a gait analysis with us and lo and behold, take a look at some of these metrics. If these look familiar, you shouldn't be surprised. So here is a much shorter, more muscular adult female with almost the exact same temporal spatial parameters as our young lanky high school runner that you just saw. And I didn't do this on purpose. Exact same cadence, center of gravity, vertical displacement, again, almost 25% higher than the female norms, step length over a meter and her stride width exactly the same at seven centimeters. Stance time not too bad at about 43% of the gait cycle and her natural running speed right now is 6.4 miles an hour. So for her, her problem areas are also the same as the young man that we talked about. Cadence, vertical displacement, step lengths and stride width. So let's take a look at what she looks like. So the first thing you notice is that she has kind of a, this is the gestalt, this is not a scientific term, that's a laissez-faire run. She has always liked to try and run fast and really over stride. She's always been coached to take long steps. She was very fast as a high school runner, but if you look at what she's doing, first here on the left-hand video, she has huge crossover, swinging those legs, circumducting them around and landing her foot right in front of the center of gravity. Why does this happen? And I'm gonna stop it right here. So if we look at this video, the whole reason a person crosses over and lands this way is because they do not have adequate control or strength of this motion right here. So what she's doing is basically balancing on one leg by putting her foot here, instead of being able to hold her foot more parallel. And when I show runners this picture, it clicks. They understand that they have to get their foot more parallel and look at the type of strain and stress that puts on the musculoskeletal system here. If we look at this video here from the side view, she has a very lovely footfall actually. So she is a mid to forefoot runner, and she said she's been working very hard to try and correct for that over the years. But she is landing way far out in front of her hips. And if you look at what her trunk is doing, it's maybe a little bit hard to see in these particular videos, but she swings her whole, she uses her trunk to rotate her whole upper body. It's not her arms that are actively and independently running. She's using the shoulders and the trunk as part of this motion. So what do her ground reaction curves look like? And they actually look quite lovely. This is what we want runners to look like. So if we had to pick an ideal view of what our GRF curves look like, it would be this. So first we look at our peaks. Are they symmetrical? Left and right, shown in our blue box over here. Yep, they're pretty darn symmetrical, and they're on the low side. So even at a pretty good running speed, she's able to do a little bit of cushioning here, which I really like. What about her impact loading rates? The slope here, that initial slope of these curves are represented here, impact loading rates, and they're between 30 and 34 body weights a second. Look at how low that is. So she's on the lower end of these categories. So these responses actually look pretty good. Now, if we look at her motion, there's some areas here I'd like to point out to you. So first, if we look at her side view here, her sagittal view, her right and her left sides actually look pretty symmetrical. She has some extra motion here, a lot more flexion. When we look at the foot position, a little bit more knee bending. I don't mind knee bending, that's not bad. If we look at the hip bending, look at this weird position right about here. This is about the part where she's doing push-off. It's almost like she's doing a little bit of a stagger or staying a little bit too long falling into that position around push-off. She also has a pretty bumpy motion here when we look at the pelvis rocking back and forth. So we've got to work a little bit more on controlling of that motion at push-off, a smoother transition. Here is where we run into some problems when we look at the frontal view. Her feet, if we look at the position where it's detecting that her soles are in, this does not mean that she's fully supinating, although she's doing a little bit of it. What the motion sensors are detecting is this huge crossover. So again, it's the overall leg that's swinging out in front of the body, not just the foot. That needs to be corrected. Secondly, her knee forces are very large. So if we look at this second panel right here, it's showing us that she has very large varus knee moments. That means as part of this crossover, it means her muscles are tugging and pulling incredibly hard around that knee joint, and that's creating a twisting force in the knee, which is very stressful for the menisci, but also for the connective tissues that are surrounding the knee joint. So it's not really a surprise where she has continued recurrent lateral knee pain here. In addition, if we look at this panel, looking at the hip motion, what this is detecting for us is huge hip adduction and pelvic drop. So these, when we put them all together, are creating a huge shearing force, if you will, particularly on the joints, but then also placing a lot of tension on the lateral sides of the leg, around the IT band as well. So I think we may have found our culprits here. If we look at the pelvis motion itself, a little bit of extra hip motion up on the right side, but not bad. The main focus is gonna be here at the knee and the pelvic drop and the foot crossover. If we look top down, so through the skull and looking down toward the feet, not too bad. A little bit of variation here that can be corrected once we get better control overall of our kinetic chain. And then finally, if we look at this picture here of the pelvis, looking down at the pelvis, it's telling us that the right side of the pelvis is tending to be out in front, leading the charge during each gait cycle a little bit more. So some of these responses are problematic. It's not the forces, it's the temporal spatial, and it's our movement that we need to get control of here. I wanted to show you this still picture of her computer model. This is what is also contributing to these huge knee varus moments. This is what we can't see with the naked eye with just 2D filming and why in some instances, 3D filming can be very, very effective and help us understand as part of this assessment, this injury assessment. So if we look at her position here from the front, the first thing you notice is that this is her balance point. I always center at the balance point first. She is completely turning her entire torso off to one side and to compensate for excessive turn, the lower body has to in turn, rotate excessively to keep the body moving in a straight line. Otherwise we'd end up running in a big circle if we let her go. So counter rotation occurs on the lower body when we have excessive rotation in the upper body. And look at this blue line, which is representative of the direction of where that force is being applied to her body. So if we look, it's going through the knee joint, excuse me, going through the knee joint, my correction, it is going through the ankle, but away from the knee joint, especially on this right side. So the farther away this blue arrow is away from the knee joint, the greater the twisting force at the knee. This is her culprit. A little bit less on the left side, but huge on the right side. So over the years of not correcting these mechanics, when Dr. Kevin talked about this at the very beginning, we go right back into the vicious cycle of not correcting the biomechanics. And she kept having these problems over the years. She has made some corrections to her mechanics, done some strengthening to correct some of these, but most of this came from dropping back the volume and really working on her form. And now she's able to run five miles with minimal pain at the knee. It's still there, but it's minimum. So we've just got to keep chipping away at it. And when she fatigues, she pulls back and stops the running. So it's nice to see some improvement. So for her therapy goals, her job now is to really work on fast cadence and short steps and really improve what we call her pedal-like motion. So I encourage our runners to think like a cyclist and really work on constrained pedal-like motion or jump roping motion. Whatever visual works for them is the cue that is going to be the most effective. So somewhere between that 175 to 182 step range is going to be good for her to get her mechanics where they need to be. And it's working. We also, for her, need to work on linearizing the torso and arms. So instead of crossing and rotating, we need to keep the torso more robotic and use the arms to do the linear motion in the sagittal plane and keeping them moving without crossing in front of the body. That's going to be critical to her. For her therapy, we need to really working on activating the core. She's strong enough. She has strong muscles. She just doesn't use them during the running. So during the stabilization part of the gait cycle, during the stance phase is what we really need to work on. And the long-term goals is being aware of the fatigue and do not push through the runs if pain is present. Break it up into smaller runs and do intervals if necessary. And then using the time afterwards to determine whether or not the volume or distance was too high. Let pain be the gauge. And then continue maintaining this running and strengthening program three to four days a week. The last runner we'd like to share with you today is a master's runner. And she does a lot of trail running. And she presented here with a very unusual femoral shaft stress fracture. So she's 61 years of age, 163 centimeters. She's been running for over 40 years and her big joy in life is running trail events all over the world. So she likes getting out there and experiencing the open air. She presented to Dr. Kevin with recovery from a recent posterior right femoral shaft stress fracture. It occurred after a long trail event in South America with unaccustomed hill terrain. So it was one of those situations where it was a ramp up of sudden volume, was unaccustomed and unprepared for this hill terrain. And she wanted to know afterwards, did she think her mechanics had caused the fracture in any way, shape or form? So here's where the 3D analysis is useful for providing extra information to prevent future injury. In her case, if we look at her temporal spatials, her temporal spatial parameters, these are gorgeous. Her cadence naturally is 181. The center of gravity vertical displacement was actually less than her comparative norms, about seven centimeters. Her step lengths were almost identical and very short. I love this. This looks terrific. The exception is there's a little bit of asymmetry between the right and the left, which we'll keep in mind. Stride width is the widest of all of them. So about 11 centimeters. And then finally stance time is a little bit different than the others between 47 and 49% of the gait cycle. So she's staying on the ground a little bit longer compared to the other runners. This is what she looks like when she runs. See if we can. So very different form compared to the other two that we've seen before. She is an exception to the rule where although she's a heel striker on one, she is a mid to forefoot striker on the other foot. So she has a mixed landing pattern here. Also notice from the side view, she leads with her arms. Most of her arm motion is happening in front of her body and less is behind her. From this panel, if we look at the right view, pay close attention to the trunk swing here. We have something very different compared to our previous two runners. She's a little bit stiffer in how she runs overall, but she really uses a lot of lateral side-to-side movement with her running. But what I do like is that she's trying very hard to keep space between her feet with a parallel foot pattern. So a little bit different. What do her ground reaction forces look like here? Hers are very different compared to the other two. One was very smooth, one had a big spike. Hers is a little bit unusual on the top of each of these curves. So what we see here on the left foot and the right foot is that they are asymmetric loading patterns. If we look at her peak forces here, they're close, slightly different, but they're close, but they're still low. That's still acceptable to me. I can live with that because they're both still pretty low. If we look at how low her impact loading is here, it's incredible. Only 39 to 40 body weights a second. Compared to the other runners in her group, she's among the lowest. So this is delightful to actually see these kinds of responses. Very controlled in how she's landing on the ground, which is probably in part why she's been able to run for over 40 years, because she's kept everything constrained and not tried to do things that were above and beyond what her body could tolerate. What is different is the shape of these curves. So this tells us when she lands on her left side, it's a little bit stiffer, and she tends to have a slightly higher loading peak here compared to the right. What is also different are these. These are the side to side forces. Here, this tells me she's using a lot of lateral motion, and she's also getting a lot of side to side component of this ground reaction force. This is a little bit different. From her position, she is also a little bit asymmetric with how she loads. Now, remember that the previous injury was on the right side, a right femoral neck stress fracture. So here actually, she's not loading too badly. She's got a pretty nice symmetrical form here. Look at her pelvis, almost horizontal. The forces are almost going through the knee joint. There's a lot to like about that right side, but take a look at the left. So what she's doing is she's using her body laterally to get herself moving forward, almost a little bit like a waddle. So for this person here, and again, it's not horrible because she's keeping tight control of the pelvis motion here. Again, not horrible here with the forces going very close to the knee joints as well. So I just think over time, she's adopted this side to side, and we tend to see that even in walking with older adults, there's more of a medial lateral motion here. So if we look at her overall motion patterns, I have to say there's a lot that I actually really like. Couple exceptions, when we look at her side view here, yes, there is a little bit more of a stiffer loading pattern that we can see here less overall motion at the knee and the hip here on the left side, which we could see. So because she's stiffer, she's using her trunk more on that side. The main difference here is that she is a heel strike on the left and a mid to forefoot on the right, a little bit different. Her pelvic motion is exactly where it needs to be, smack dab in the middle, a nice neutral position. From the frontal point of view, she's got great foot position, low knee forces. But here, when we look at the hip motion, she tends to actually open her hips out compared to the other runners. Others dropped in and had a lot of pelvis motion, she did not. So when she landed, she tended to turn out a little bit. And that I think actually gives her a little bit more stability when she lands, which goes along with a little bit of a waddling style. Pelvic motion looks great. And again, foot motion looks pretty darn good looking top down, little bit of variations here again, because of this weird lateral trunk swing here. So is there really much to be concerned about? At this point, I would just really keep an eye on this and keep with the strengthening and as much of that motion control as we can. So with her, there's nothing that I see here that really contributed to that type of stress fracture that she got. So in looking back, Dr. Kevin and I had some discussions about this, and we believe that for her, it was the unaccustomed volume at that trail type of incline and decline that she was unaccustomed to it. And it was an acute event that triggered the fracture. So we stay the course and follow this post-stress fracture return to run program and continue strengthening of the lower limbs instead of using the trunk sway to control the movement. And the long-term goals for her are really try to load the extremities equally and avoid this compensation overload on that left side. In the future, when preparing for long runs, start the months ahead to prepare for whatever terrain that she's going to be dealing with to avoid acute mechanical overload. So even using treadmill training as a way to do hills up and down to better prepare for this and avoid the acute stress fracture. And then lastly, we also wanna keep our patients informed. So over the years, we've developed a variety of different infographics and brochures in part through the American College of Sports Medicine as our partner. We want to make sure that our patients are following up on healthy running changes over time, selecting appropriate shoes, understanding what to look for and developing the right habits. So our summary points here is that we can use our three-dimensional analysis as well as educational materials to better educate our injured runners about what are healthy patterns and to develop clinical plans of care. And what we've found over the years as part of our research and part of our experience really is understanding what's most likely to produce injuries in runners includes a low cadence, high impact loading rate, foot crossover, excessive hip adduction and pelvis vertical displacement, too much bounce. In addition, identification of these specific aberrations can be used to inform our therapy strengthening as well as to help our runners retrain appropriately and adopt our healthy habits. Thank you so much for attending. Can I answer any questions through the chat forum for you? We hope you have found these tips useful, what we've learned over the years. Please don't hesitate to reach out to either of us. Our contacts are here. We're happy to answer your questions. Thank you so much, everybody.

clinical examination

functional assessment

injury prevention

runners

psychological factors

multidisciplinary approach

3D analysis

running mechanics

case examples

intervention

tailored training

running injuries