A Primer on Running for the Orthopaedic Surgeon

Andrea M. Spiker, MD; Ken B. Johnson, PT; Andrew J. Cosgarea, MD; James R. Ficke, MD

J Am Acad Orthop Surg. 2020;28(12):481-490.

Abstract and Introduction

Abstract

Long-distance running has become increasingly popular during the past decades. Many running patients pose questions to their orthopaedic surgeons regarding risks, benefits, and running techniques. This article identifies 11 running-related questions that patients may ask and provides information to help answer those questions. This review discusses data on the health benefits of running, common running injuries, the relationship between running and osteoarthritis, recommendations regarding running after orthopaedic surgery, running shoes, and other questions that may arise when treating the running athlete.

Introduction

Running is an increasingly popular pastime for Americans, reflected in part by the number of participants in running races. In the United States, the number of race finishers has increased by >360% since 1990, from 4.7 million to 17 million in 2015. The proportion of female runners during that time has grown from 25% to 57% of finishers.^[1] In 2015, >509,000 people finished 1,100 marathons (competitive races of 26.2 miles) in the United States.^[1]

Cardiovascular fitness protects against obesity, chronic disease, brain atrophy (in those at risk of dementia), and cancer.^[2] Physical activity at low levels (92 minutes weekly or 15 minutes daily) has been associated with a 14% reduction in death from any cause and a 3-year increase in life expectancy. Each additional 15 minutes of daily exercise is associated with a further 4% reduction in death from any cause.^[3] Running can increase cardiovascular fitness and improve physical activity levels, aerobic fitness, and cardiovascular function, as well as metabolic fitness, adiposity, and postural balance.^[4]

However, there are risks associated with running, especially at levels and durations considered "above average." Each year, 19% to 79% of runners report lower extremity running-related injuries, most commonly at the knee.^[5] Orthopaedic (musculoskeletal) injuries in runners can be acute but are more commonly chronic and caused by overuse. The goal of this review is to present evidence-based answers to common questions from runners to guide orthopaedic surgeons in treating and counseling these patients.

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Abstract and Introduction
Common Patient Questions
Summary
References

Table 1. Common Running Injuries
Injury	Cause/Description	Treatment
Hip
ITBS	Can result from friction against the greater trochanter. Is worsened with running on banked surfaces, downhill running, leg-length discrepancies, and genu varum.¹⁵	Rest, NSAIDs, and physical therapy to treat symptoms. Only rarely is surgery with iliotibial band release or lengthening considered.¹⁵
Snapping hip syndrome	Can be external (more common, caused by iliotibial band, tensor fascia lata, or gluteus maximus sliding over the greater trochanter) or internal (iliopsoas tendon sliding over the iliopectineal eminence, lesser trochanter, femoral head, or hip capsule).	Rest, NSAIDs, and physical therapy to treat symptoms. Only rarely is surgery with iliotibial band release or lengthening considered (for external snapping hip).¹⁵
Femoral neck stress fractures	Can present as anterior hip or groin pain that is worsened by running and can radiate to the thigh or medial knee. Women have a higher incidence of femoral neck stress fracture, and patients with a lower body mass index (<19) or higher MRI grade of stress fracture require longer return-to-running times after diagnosis.¹⁶	Nondisplaced compression-sided or medial stress fractures can be treated nonoperatively. Tension-sided or lateral stress fractures are considered to be at higher risk of displacement and nonunion; hence, early surgical intervention should be considered.^15,16
Knee
Anterior knee pain (previously known as patellofemoral pain syndrome)¹³	Excessive hip adduction and hip internal rotation or external rotation weakness have been implicated as causes. These positions theoretically displace the patella laterally against the femur, causing increased pressure at the patellofemoral joint, which leads to pain.¹² Patients present with anterior knee pain, worse with squatting or prolonged sitting, and may show vastus medialis oblique muscle atrophy or the J sign.¹⁷	Nonsurgical treatment (activity modification, NSAIDs, and ice) and physical therapy focused on quadriceps and core strengthening and correction of neuromuscular dysfunction.¹⁸
ITBS	Can be caused by friction at the lateral femoral epicondyle, compression of tissue deep to the iliotibial band, or bursitis. It may present as diffuse lateral pain or lateral knee snapping.¹⁷	Nonsurgical treatment (activity modification, NSAIDs, and ice) and physical therapy.
> Popliteal artery entrapment syndrome	Occurs when the popliteal artery is compressed by anatomic variations at the back of the knee, which can include abnormal origin of the medial head of the gastrocnemius muscle at the intercondylar notch, aberrant fibrous bands, or a medial position of the popliteal artery. Presents similarly to chronic exertional compartment syndrome of the lower leg.	Because of the progressive natural history, as well as the cause of this syndrome, surgery is often warranted.¹⁹
Lower leg
Medial tibial stress syndrome	Presents as exercise-induced pain at the midto- distal posteromedial tibia. Thought to be caused by abnormal traction of the calf muscles or overloading of the tibial cortex. Risk factors include female sex, high body mass index, uneven running surfaces, sudden increases in running intensity or distances, and excessive foot pronation.¹⁷	Activity modification, stretching, ice, and NSAIDs. A trial of 6–12 wk of nonsurgical treatment is attempted, and if this fails, rarely is surgical release offered as a treatment.¹⁷
Achilles tendinopathy	Presents as posterior heel pain with tenderness often 2–6 cm proximal to the tendinous insertion on the calcaneus.	Activity modification, stretching, ice, and NSAIDs.
Gastrocnemius strains	More common than soleus strains because the gastrocnemius muscle crosses two joints and consists primarily of fast-twitch type-IIB fibers. The gastrocnemius can be injured with faster-than-normal running speeds and suboptimal foot touchdown, which lead to alterations in the muscle length and shock absorption.¹⁹	Activity modification, stretching, ice, and NSAIDs. For severe gastrocnemius strains or ruptures, splinting in plantar flexion for 3 wk can aid healing.¹⁹
Chronic exertional compartment syndrome	Typically presents with pain at a relatively consistent time/distance after the onset of running and dissipates with cessation of running. Bilateral presentation is frequent. Most commonly, the anterior compartment is involved (45%), followed by the posterior deep compartment (40%). The lateral compartment (10%) and posterior superficial compartment (5%) are less commonly involved.	Activity modification, stretching, ice, and NSAIDs. Surgical fasciotomy of the involved compartment(s) is the definitive treatment of refractive cases that have met appropriate diagnostic criteria.²⁰
Tibial stress fractures	The most common (approximately 50%) stress fracture seen in runners. As with all stress fractures, results from the mismatch of bone resorption and remodeling caused by repetitive stress and inadequate time to remodel. Patients present with focal pain that increases over time and begins earlier after the onset of running than with other diagnoses, such as medial tibial stress syndrome or shin splints. Radiographs may not clearly show a fracture line in the first 2–3 wk.¹⁷ Risk factors are being active for <8.5 yr or being female with a body mass index <21 kg/m².¹⁴	Treatment of high-risk (tension-sided or anterior cortex) stress fractures can include non–weight bearing, immobilization, and possible early surgical intervention.^17,19
Foot
Plantar fasciitis	A degenerative process resulting from repetitive microtrauma of the plantar fascia origin at the heel. Patients present with posterior heel pain, worse with the first steps in the morning or walking barefoot.	Ninety percent of cases resolve with nonsurgical treatment and optional use of foot orthotics and night splints; however, the duration to symptom resolution is long, often 6–12 mo.¹⁷
Stress fractures	High-risk (high risk of nonunion) stress fractures of the foot include fractures involving the medial malleolus, the base of the second metatarsal, the fifth metatarsal diaphysis (Jones fracture), the tarsal navicular, and the sesamoids. Lower-risk stress fractures can occur in the calcaneus, the shaft of metatarsals 2–4, or the metaphysis of the fifth metatarsal.	Most stress fractures of the foot can be treated with immobilization and non–weight bearing. High-risk stress fractures such as the Jones fracture can be treated with intramedullary screw fixation and bone grafting, resulting in return to play as early as 12 wk.²¹