Common Running Injuries
Mr Maurice O'Flaherty

Good evening, everybody my name is Maurice O’Flaherty; I am one of the consultants here in UPMC Sports Surgery Clinic I am here to talk tonight about common running injuries.

First, a little about myself, I’ve been a consultant orthopaedic surgeon for 14 years and I work mainly in the UPMC Sports Surgery Clinic in Dublin. I did a masters in sports medicine and exercise in the university of bath in England. I am myself a keen runner I try to do 10k 2 to 3 times a week and I also go to the gym.

Why does it matter? well if you’re anything like me this is happy you when you’re out running, its not just good for exercise its good to clear the head, and also if you’re anything like me this is you when u aren’t running or you can’t run due to an injury or there is something going on. Between the two things obviously running does matter or you wouldn’t be attending the webinar this evening.

If we move on, what are the typically running injuries? Ive done my best tonight as to not go into any medical talk this is just to go over the common injuries and then Colin will talk about rehab and that. So, the main thing that I see all the time are Achilles Tendon injuries, bone stress injuries, plantar fascia and of course sprained ankles.

Why me? everybody asks why is it happening to me, what’s going on? Is it me that’s hurting my ankle? Is it me that’s hurting my Achilles? The answer is that there are many contributing factors. The first one and most common one that we would see if over training or doing too many events and too many things going on and just not taking enough time to take a break and give your body time to recuperate. I have a picture of a pair of trainers there because believe it or not there is a big difference in some of the trainers out there, some of them may have a zero heal drop like the Altras to put a little more stress on the Achilles and a little less stress on the knees. Other ones like the hokas have quite a large heel to toe incline so some of them are 12mm so they’ve got quite a big stability sole. If you’re between one or the other and haven’t used them before that can lead to injury. The other pictures if you transition from road running and you’ve done road running all your life and you decide to take up trail running but again obviously these have different demands on the body that can lead to injury if you are not used to them or haven’t prepared.

So, one of the big things you’ll find that they touch on is your gastrocnemius, this is attached to your Achilles. What’s the big deal? Well, a lot of studies in recent times say the gastrocnemius and the Achilles have been interlinked with problems with the foot, the Achilles and ankle problems so they are pretty important as you will see.

An Achilles Tendinopathy, what is it? What causes it? Symptoms, Mid-substances versus Insertional and When do you come see me?

First thing is, what is it and what causes it? Well, as you may know the Achilles itself links the gastrocnemius and the flesh itself to the heel bone. It’s the strongest and longest tendon in the body and it can take up to 10 times body weight under tension. It powers your stride, and every step stretches and contracts it, it plays a very important role when you are running. You might be saying “this guy is crazy, what’s he putting up a picture of spaghetti for” well I think this is the easier way to think of the Achilles tendon and when we go onto the plantar fascia. If you imagine the Achilles tendon is made up lots of lovely stripes of collagen fibres if you look at it under a microscope it looks very like the picture of the spaghetti I show here, and really it moves away from the idea that its tendonitis its more of a tendinopathy. What do I mean by that? Well, it’s more wear and tear, if you look at it under a microscope it would be more like the frayed rope there on the left, there is a little bit of fraying just a bit more higgledy- piggledey overall not its normal self.

So, what can cause it? Tight calves which we have mentioned before, stiff ankles, poor footwear, over training and over loading all are implicated in the causes. So, symptoms you may already know yourself if you have had it, lump in the Achilles which appears tender. It can be worse getting out of bed in the morning and the reason for that being your gastrocnemius is usually very tight and contacted when you are sleeping because most people sleep with their knees bent and then you get up out of bed and stretch everything out in the morning. If you experience pain getting up from rest or if you have pain down at the heel usually down where it rubs on your footwear, either way you are usually unable to train as you normally would.

When do you see me? Well, if its chronic going on for more than 3 months, if its not improving with stretches or self-management or if physiotherapy is not working, we go the treatment ladder and see what step is next.

So, what can I do? well as usually take a good history from you, examine you and get an MRI scan if you haven’t had one done. One thing which we find very useful which if you have a lesion like that on the back of the Achilles is a hydro-dilatation not everybody is suitable for it but if you are we basically strip off the jacket that encloses the tendon and has some of the nasty blood vessels that grow around it and bring in the nasty pain chemicals and we strip these off and that usually gets back to more suitable base line level where you’re not as sore and a physio can work with you again. Achilles lengthening is very useful via gastrocnemius release it’s a very small day case which we sometimes do if a calf tightness is the main thing driving it. One of the main things about Achilles and Plantar Fascia is if you don’t get rid of the calf tightness or you can’t then all the other ways or trying to get you better don’t really work very well, they are not as effective. PRP injections, a bit more evidence for these nowadays, very limited but there are certain times when they work very well. And then surgery would be the last resort.

The next thing then, Bone Stress Injuries, what do I mean by that? Well on the left you can see one picture this is your heel here on the bottom and hen on the right you can see the same picture but it’s a bit darker. The one on the left is the abnormal one and that is the one with the bone stress in it, the areas of white on the left-hand side photo should not be present in the bone. Okay well what is that? I try to describe it like a crunchie bar and if you can imagine crushing a crunchie with your knuckle the chocolate on the outside might be okay but the honeycomb on the inside may be a little stoved in and a little bit watery. Now, why is that? It’s essentially a bit like a bone, there can be an overuse it can be common in runner, this can be for a variety of reasons. It’s usually trauma or overuse it can be metabolic due to your metabolism and your hormone imbalance, or it may also be due to inflammatory conditions. What happens in all of them is that fluid accumulates in the soft bone and it leads to pain swelling, and it often worsens with activity. Quite often people do a limb of things like that.

So, what do I do? We very importantly off load the area that’s injured, quite often this would require 6 weeks in a walker boot. This would typically settle down the acute phase and in that time, we also check your Vitamin D levels which unfortunate in Ireland were very low in obviously with very little sunlight. We also check your thyroid functions as sometimes that can be a bit off as well. If we are concerned about you bone density, we will get a DEXA Scan and sometimes you get a close to injury MRI but more that usual we find that you have settled down from your time in the boot. And if we have checked all the other things the more important thing would be to check your biomechanics, your running pattern and get an orthotic if need be.

So, moving on Plantar Fascia is the next thing, what does it do? Well, the plantar fascia believe it or not is very important, it’s a shock absorber mainly in the heel it transfers force across from the heel to the toes. Again, this is made up of type 1 collagen, again I go back to the original picture of the spaghetti under a microscope, lovely straight fibres, very uniform and then when you look at a Plantar Fasciopathy, not fasciitis because there is no real inflammation involved. You can see that this looks like rope on the left, a bit frayed, this is also why anti- inflammatories don’t tend to work because it isn’t true inflammation.

What can cause it? Well, this is one where tight calve muscles are implicated quite a lot it is very important to assess the tightness of the calves this is the number 1 thing that should back tackled before doing anything else for plantar fascia issues. Usually, it comes on as a result of overuse or activity, if you’ve got a high BMI and are overweight you are more likely to develop it. Occupations where you are standing for long periods of time on hard floors in poor footwear can also be the cause, poor biomechanics can also lead to it.

The good news is that in the majority of cases 80pc of the time physiotherapy will settle it down. If that doesn’t work that’s when I tend to see you again. The things we would do – calf releases for tight calves, shockwave therapy works very well in cases where physio hasn’t been successful. We don’t inject plantar fascia, well I certainly don’t recommend injections all the evidence shows that it just gives a short time fix and then it comes back again, then you add to the risk of rupturing it so I don’t do it. However, there is a bit more evidence for PRP injections again in limited cases and depending on MRI appearances, that is something we sometimes consider. Finally, if we get o the top of the ladder we discuss earlier and you haven’t gotten better then one of the operations I can do in a keyhole plantar fascia release, it done as a day case, very tiny scars on either side of the heel. You get going again within a couple of weeks and it tends to work very well obviously again it is a last resort.

Moving on then to ankle sprains, so what do we mean by an ankle sprain. Well, the majority of runners are going to be concerned with a lateral ankle sprain, a high ankle sprain is another type but in runners this isn’t seen too often. The picture on the left shows the ligaments, the ATFL, the TFL and the CFL and then on the right-hand side you can see the syndesmosis ligaments.

Syndesmosis injuries are also known as high ankle sprains, they are difficult to recognise unless you have a physio who’s really on it and knows what they are talking about. Its very uncommon in runners so we will only touch on it, there is usually about half a percent of the ankle sprain seen. Much more commonly then we have our lateral ankle ligaments that are injured, you can see it clearly in this picture here., ATFL and CFL, PTFL nearly always in intact because in the majority of cases in which you roll your ankle your foot is pointing down to ATFL and CFL are in tension and PTFL tends to be relaxed therefore it is not injured as often.

So, what happens? Well, if there is an inversion injury or rolling your ankle a lot of people will hear a pop or a crack at the same time. You are immediately unable to play on or run on, you get severe pain and or swelling and bruising develops shortly after. People talk about hobbling about for a few days after, many go to their local A&E department and will have an extra taken and be told “there is no fracture, on you go!” If you are very lucky you will get a boot and then you will see you physio. Sometimes you may have an MRI but if you are not seeing improvements that I when you will be sent to see one of us.

So, what does the MRI tell us? Well, it usually informs me about the lateral ligaments. So, the ATFL and CFL, as I said before, PTFL is usually fine. You’ll have a Synovitis and this is just a reaction of the capsule around the joint with a lot of inflammation going on and you’ll see sometimes Bone Oedema in the talus as we touched on before the Bone Oedema is just bone bruising and that means whenever you roll your ankle, sometimes the bones hit together very quickly for a short period of time and then it goes back to the normal position. That leaves a bit of bone bruising in the bone that itself can be a pain generator. Finally look at Syndesmosis in the deltoid ligament but in the running injury unlikely to have hurt those.

So, who is this? Well, some of you might recognize Tony Feno back in 2018 he was doing the par three competition at the Masters and he got a hole in one in the seventh hole ran off to celebrate and then rolled his ankle. I mean on the left there you can see a severe ankle sprain so it can be a significant injury. With regards to lateral ankle sprains, as I say, physios are wizards, majority of the ankle sprains like this, functional rehabilitation is the key. We don’t just keep the ankle straight and doing nothing, it’s very important to get it moving in specific ways and that’s what the physiotherapists are amazing at. It is Usually referred to me if it’s unstable despite physio, you’ve got ongoing pain or if you are a high-level sports person trying to get back sooner. In the majority of cases, any surgery or anything that needs done can wait or be managed up until the time is right.

What do I do? Well, one of our best operations that we do is a lateral ligament surgical reconstruction and it involves two parts. One is looking inside the ankle and clearing out any scar tissue. That’s the ankle arthroscopy or keyhole bit and then the other bit is the lateral ligament stabilisation, which is reconstructing those ligaments again and trying to make them tight. On a first go, it’s generally a ‘winner’ operation, it can be done in the off period

of your sports or your activities. Usually, done as a day case you’re in and out the same day, general anaesthetic and it takes about an hour to do and your couple of small cuts, they’re reconstructed with special suture anchors that we have. The recovery is fairly quick, so days 1 to 10 is just getting over the operation itself and letting the wounds start to heal. From Week 2, we get you out of the cast and into a walker boot and get you fully weight bearing in the boot and start specific ankle movement exercises. About Week 6, we increase those exercises and aiming towards a return to some sort of sport by month three. Again, the physiotherapists are all instrumental in the in the recovery.

In conclusion, then communication between the physiotherapist and radiologist in any of these issues is key and they talk to us. All of these are best managed in high volume centres like the UPMC Sports Surgery Clinic, you want to be going somewhere where they see these things all the time. As you probably know, you have stories of people being coddled along for months and not really getting anything done, it is important if you think something’s not right, just to come and get checked out. Runner’s injuries in particular are varied in presentation and the clinical picture really guides what imaging we request and when we request it. and the images we get then helps the surgeon choice as to what we do.

And that’s really it, that’s all I wanted to say this evening. If you have any questions, just remember the answer is always that it’s science. Thanks very much.

Asking you for your favourite shoe for running is a bit like asking you what your favourite type of car is, everybody will have their own answer. I suppose it depends really a lot on what you’re looking to do, some people are looking to do longer runs like half marathons, marathons. Suppose the most common type of trainers out there that we see all the time are HOKAs, they have very good cushioning, they have a good heel to toe which makes them easier to run in. The heel to toe is about 12mm or so it’s quite high. So, people who have knee problems and who like to do a bit more like barefoot running. Well, that’s when we talk about the Altras because they actually are zero heel drop, they have a wide toe box they can be plush as well. They can help people sometimes who have pains in their knees when running. You’ve also got Brooks, and the Asics gel Nimbus, which are very good for distance. If people are doing tempo runs, they sometimes use the HOKA Mac 2 or Mac 3, the sort of lighter trainer. So really there’s a vast majority out there that can help people.

I think the best thing to do is to go to somewhere in your local town or city that is a proper running shop, not just a trainer shop, but a proper running shop, they’ll give you lots of advice. For example, in Dublin here, there’s Run Logic, they give very good advice, and you can try the trainers on, some of them will even have a treadmill you can run on and be filmed on so they can look at your pronation or supinator. There’s lots of different tweaks to all the trainers nowadays. if some of them have a medial guide which means that they’ll help you if you’re a pronator and other there’s that can go the other way. It’s really individualised now compared to the days of just sticking on a pair of Nike Pegasus and running as far as you can

This is probably the most common thing we see, there’ll be quite a lot of times where patients have a history of going over on their ankle or they roll their ankle, and the common history is if you’ve done it once and you do it again. Quite often it’ll swell up almost immediately because what happens is the inflammatory cells that go along with that incident are already there in your ankle and they’re ready to kick off again very quickly. But also, the swelling goes down quite quickly after a few days and people get going again to the point that they probably forget about it and get back to running or whatever they’re doing. Some people have had physiotherapy and usually as I said in the talk that works very well.

I think probably when I should see you it is if you’re if you’re running and you feel like you’re going to go over on it all the time or if you’re doing simple things day-to-day like walking on a cobble street, taking the bins out at nighttime and you feel you’re rolling over on your ankle. Well then that’s another indication that you can do all the physio in the world to but it’s not really going to help that problem. So, we’d really like to see those patients come to see us because it is a very good operation to sort it out if it’s got to the stage where physio alone isn’t working and we can really stabilise that and get people back to a good degree of sport again.

The name has just given away, so, it used to be called policeman’s heel. The reason being it was all policemen and policewomen got it. If you look at the literature over the last 5 to 10 years planter fasciopathy a lot of it is this the breakthrough and the fact that it’s not an inflammation thing, it’s not an itis it’s a fasciopathy and that then stems from the fact that the calf muscle is very integral to it. Even though they’re not technically connected, the calf and the Achilles down over the heel and then into the planter fascia really works as one big unit. So, if you can keep the planter fascia stretched out, i.e. by stretching the calf and the hamstrings, then that is the majority of the issue solved. You may need a bit of tinkering then with all the other stuff, but the calf tightness is the number one thing to get rid of initially.

The PRP it was a bit dubious as to whether it helps for everything, it probably doesn’t help for everything yet and there’s other stuff we don’t know it will help for yet. It’s still being looked at, it’s early days. But the thing I find it very useful for is like in the presentation when I was talking about the rope being frayed that’s called an interstitial tear. So, in other words, the little tears that that are present in the tendon, PRP into that does definitely help both in the planter fascia and in the Achilles tendon.

If you’re having trouble still, well then usually that’s then a time to see one of us because quite often the MRI will show up things like calcium in the tendon where it inserts into the heelbone. The heelbone itself might have a slightly abnormal anatomy which makes you more prone to it, a thing called a Haglund Deformity. And again, that can be the thing that irritates the tendon, or it could be the thing that’s in between the tendon and the heelbone which is called a Bursa (A fluid filled sack). They’re all over the body to prevent friction, but the one in your heel is particularly prone to getting inflamed, to getting angry and it could be something like that as well. So, there’s quite a lot of anatomy around that one part of your foot that needs taken into consideration when deciding what to do next.

If you’re getting steroid injection into your big toe and you’re aware that the joint is a bit smaller than it used to be, then it sounds to me like you have a thing called Hallux Rigidus. We grade it from 1 to 4 with one being not too bad at all, four being the worst. Believe it or not, MRI is good, but X-ray is actually the best, the standing weight bearing X-ray, which you can get when you come to see us, allows us to get certain views. That really determines what you can do because after a while, no matter how many injections you put into it, it won’t help. The rocker sole in the trainer is a bit like the old-fashioned insoles that you used to get for it, which was called a Morton’s blocking splint, and it basically stops your big toe from dorsa flexing up, that’s just really for pain relief. I would say if you’re having symptoms like that in your big toe, the earlier we can see you in terms of looking at the degradation of the joint, the better because really you go from not 0 to 60 very quickly with toe arthritis and you either have nothing done or you can end up with needing a fusion done which makes it a bit harder to run.

There is an in between operation called the cheilectomy, which if you’re a grade two three or if in certain conditions if the x-rays prove that they can do it then it’s it works very well and it maintains the movement in your big toe which is a big thing if you’re a runner. So, I would encourage you to be seen early. If you’ve had a couple of X-rays guided injections into the toe and you’re still sore, it’s probably time to come and see one of us just to make sure you don’t go too far because you might be able to keep the movement, and it might help you.

The concrete will give you a bit more impact, you know, force through the ankle, force through the feet. But conversely, it’s probably worse for your ankle running on grass or on sand. It’s sort of an urban myth that you’re better not running on flat concrete because if you imagine the stabilisers of your ankle on both the outside of the ankle and the inside and it’s different muscle groups and tendons that do that, but there’s also ligaments involved, which is like the lateral ligaments I was talking about in my talk and the inside ligaments. So those ligaments all don’t like very much being on uneven ground because there’s constant adjustment to the undulations in the ground and actually, it’s much less stress on your ankle or your foot to be running on flat floor.

So yes, and yes. Collagen supplements, I mean there’s plenty of information out there on them. The marine collagen is probably the one with the best evidence behind it at the minute. But then you also have the nutritionists who say if you have a good protein in your diet, there’s really no need for collagen supplementation. So as long as you’re getting your 30 to 60 grams of protein a day, you shouldn’t really need collagen peptide supplementation. So, menopause, unfortunately, yeah, that does affect the tendons, and ligaments, it also affects bone density. So, it’s quite a common one for the bone stress injuries is the hormonal imbalance that sometimes comes with the menopause.

It sounds suspiciously like Achilles tendinopathy at the insertion. So, where the Achilles inserts into the heelbone that would be probably the top likelihood of it. You could try doing a bit of stretching and hope that it goes away, the calf stretches but again you might unfortunately that person might be predisposed to having a bit of Achilles tendinopathy at that part where the Achilles inserts.