The Injured Runner - An Evidence-Based Approach: Part One - Running Injuries

The Injured Runner:
An Evidence-Based Approach
Part One: Running Injuries
Allan Besselink, PT, Dip. MDT
Director,
Smart Sport International
Smart Life Institute
Austin, Texas
Background
● Physical therapist (1988)

● McKenzie Diploma (1998)
● USA Track and Field
● Endurance sports coach
(running, triathlon)
● Educator (PT; PTA)
● Author - “RunSmart: A
Comprehensive Approach To
Injury-Free Running” (2008)
Allan Besselink, PT, Dip. MDT 2
Evidence

Evidence-Based Medicine
“The plural of anecdote is not data”

(Frank Kotsonis)
“In God we trust – all others bring data”

(Nik Bogduk)

“The conscientious, explicit, and judicious

use of current best evidence in making
decisions about the care of individual
patients.”
Sackett DL, Rosenberg WM, Gray JA, Haynes
RB, Richardson WS. Evidence based
medicine: What it is and what it isn't. Br Med
J, 1996; 312:71–72.

But, one problem exists -
– Evidence is of no use if it is not integrated and

utilized in the assessment and treatment algorithm
– Evidence must also extend to consumer awareness

Belief Systems
The impact of the provider's belief systems

may be greater than the evidence
Ross (1994):
– “Our beliefs are the truth;
– The truth is obvious;
– Our beliefs are based on real data;
– The data we select are the real data”

Belief Systems

Belief Systems
“The inability to challenge our belief systems

in the face of good scientific evidence is the
primary limiting factor in the advancement of
both health care and coaching, as well as
human performance and injury prevention”
(Besselink 2008)

Belief Systems
It is a very uncomfortable struggle to integrate

evidence into your thinking – especially if it is
contrary to your current beliefs

Thinking
“To arrive at a contradiction

is to confess an error in
one’s thinking; to maintain a
contradiction is to abdicate
one’s mind and to evict
oneself from the realm of
reality”
(Rand)

Evidence ...
… regardless of it's
impact on the
provider's bottom
line or their personal
beliefs
It is an issue of cost,
of efficacy, and of
autonomy.

Lessons Learned: Back Pain
● What assessments?
● What treatments?
● Well-established clinical
guidelines
Use the lessons learned

from back pain research!

Evidence

A Brief History Of
Running Injuries
Perceived causes:

A Brief History Of
Running Injuries
Perceived causes:
– Muscle imbalances
– Lack of flexibility
– Incorrect footwear
– Leg length discrepancy
– Foot structure
– Too much speed work
– Asymmetry and mal-alignment

A Brief History Of
Running Injuries
30+ years of scientific evidence would indicate:
No specific correlation between anatomic mal-

alignment or variations in the lower extremity
and any specific pathological entities or
predisposition to any “overuse syndromes”

A Brief History Of
Running Injuries
● James SL, Bates BT, Osternig LR. Injuries to runners. Am
J Sports Med 1978; 6: 40-50.
● Jacobs SJ, Berson BL. Injuries to runners: a study of
entrants to a 10,000 meter race. Am J Sports Med 1986;
14: 151-155
● McQuade K. A case-control study of running injuries:
comparison of patterns of runners with and without running
injuries. JOSPT 1986; 8: 81.
● Lysholm J, Wiklander J. Injuries in runners. Am J Sports
Med 1987; 15: 168-171.

“Normal”
“Malalignment is a
term that should be
reserved for gross
abnormalities, two
standard deviations
outside the norm”
(Reid 1992)

In the meantime ...
What do patients continue to hear from doctors,

chiropractors, and physical therapists treating
injured runners?
● Muscle imbalances
● Lack of flexibility
● Incorrect footwear
● Leg length discrepancy
● Foot structure
● Too much speed work
● Asymmetry and mal-alignment

Evidence

MRI And Imaging
Perceived value of imaging in the assessment

process
Does the cost of imaging outweigh the
benefits?
Is imaging relevant and pertinent as a first line
of assessment?

MRI And Imaging
● Krampla WW, Newrkla SP, Kroener AH, Hruby WF.

Changes on magnetic resonance tomography in the knee
joints of marathon runners: a 10-year longitudinal study.
Skeletal Radiol 2008; 37(7):619-26.
● Stahl R, Luke A, Ma CB, Krug R, Steinbach L, Majumdar
S, Link TM. Prevalence of pathologic findings in
asymptomatic knees of marathon runners before and after
a competition in comparison with physically active
subjects-a 3.0 T magnetic resonance imaging study.
Skeletal Radiol 2008; 37(7):627-38.

MRI And Imaging
● Schueller-Weidekamm C, Schueller G, Uffmann M, Bader

TR. Does marathon running cause acute lesions of the
knee? Evaluation with magnetic resonance imaging. Eur
Radiol 2006; 16(10): 2179-85.
● Boos N, Rieder R, Schade V, Spratt KF, Semmer N, Aebi
M. 1995 Volvo Award in clinical sciences. The diagnostic
accuracy of magnetic resonance imaging, work perception,
and psychosocial factors in identifying symptomatic disc
herniations. Spine 1995; 20(24):2613-25.

MRI And Imaging
● Guten GN, Kohn HS, Zoltan DJ. 'False positive' MRI of the
knee: a literature review study. WMJ 2002; 101(1):35-8.
● Sein ML, Walton J, Linklater J, Harris C, Dugal T,
Appleyard R, Kirkbride B, Kuah D, Murrell GA. Reliability
of MRI assessment of supraspinatus tendinopathy. British
Journal of Sports Medicine 2007; 41(8).

MRI And Imaging
● Lessons learned from back pain: 70% of

asymptomatics have a positive MRI
● If a patient has a positive MRI, what does it tell
us?
● Similar data exists for shoulders and knees
● Well-established clinical guidelines would
indicate that this should not be a first line of
assessment

In the meantime ...
What will physicians and chiropractors have the

patient do as a first line of assessment?
– MRI
– Radiographs
– CT scans

Evidence

Assessment Techniques
Perceived value in the clinical reasoning

process
Three primary approaches:

– Palpation-based
– Movement-based
– Provocation-based

Palpation
● Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson

VM, Murphy LS, Reinsch S. Reliability of spinal palpation
for diagnosis of back and neck pain: a systematic review of
the literature. Spine 2004; 29(19).
● van Trijffel E, Anderegg Q, Bossuyt PM, Lucas C. Inter-
examiner reliability of passive assessment of intervertebral
motion in the cervical and lumbar spine: a systematic
review. Manual therapy 2005; 10(4): 256-269.

Asymmetry
● Badii M, Shin S, Torreggiani WC, Jankovic B, Gustafson

P, Munk PL, and Esdaile JM. Pelvic bone asymmetry in
323 study participants receiving abdominal ct scans. Spine
2003; 28(12): 1335-1339.
– Patients without back pain
– 82.7% asymmetrical; 5% > 5mm
– previous reports of 24 – 91% (in back pain
patients)
– Can this be palpated?

Sacroiliac Joint
● Sturesson B, Selvik G, Udén A. Movements of the

sacroiliac joints. A roentgen stereophoto-grammetric
analysis. Spine 1989; 14(2): 162-5.
– 2.5 degrees of rotation, 0.7 mm of translation
– No difference between asymptomatic and
symptomatic joints

● Palpation-based assessment techniques are

inherently unreliable
● What are the ramifications if two people can't
agree on what they feel – and do so
consistently?
● If there is questionable inter-rater reliability,
then what is the level of validity?

Motion/Provocation
● Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S,

Telje T. The reliability of selected motion- and pain
provocation tests for the sacroiliac joint. Manual Therapy
2007; 12(1): 72-79.
● Hancock MJ, Maher CG, Latimer J, Spindler MF, McAuley
JH, Laslett M, Bogduk N. Systematic review of tests to
identify the disc, sij or facet joint as the source of low back
pain. European spine journal : official publication of the
European Spine Society, the European Spinal Deformity
Society, and the European Section of the Cervical Spine
Research Society 2007; 16(10): 1539-1550.

Repeated Movements
● Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H.

Efficacy of flexion and extension treatments incorporating
braces for low-back pain patients with retrodisplacement,
spondylolisthesis, or normal sagittal translation. Spine
1993; 18(13): 1839-49.
● Kilpikoski S, Airaksinen O, Kankaanpää M, Leminen P,
Videman T, Alen M. Interexaminer reliability of low back
pain assessment using the McKenzie method. Spine 2002;
15; 27(8): E207-14.

Centralization
● Werneke MW, Hart DL, Resnik L, Stratford PW, Reyes A.

Centralization: prevalence and effect on treatment
outcomes using a standardized operational definition and
measurement method. J Orthop Sports Phys Ther 2008;
38(3):116-25.
● Skytte L, May S, Petersen P. Centralization: its prognostic
value in patients with referred symptoms and sciatica.
Spine 2005; 30(11): E293-9.
● Aina A, May S, Clare H. The centralization phenomenon of
spinal symptoms--a systematic review. Man Ther 2004;
9(3): 134-43.

Movement-based and provocation-based

assessment techniques – reliability and validity
Centralization as a prognostic indicator
Repeated movement testing as reliable as MRI

but with far less cost!

In the meantime …
What do doctors, chiropractors, massage

therapists, and physical therapists continue to
utilize as a primary form of assessment and
upon which they base their clinical reasoning?
– Palpation-based assessment techniques

Evidence

Treatment Interventions
Perceived Causes:
● Muscle imbalances
● Lack of flexibility
● Incorrect footwear
● Leg length discrepancy
● Foot structure
● Too much speed work
● Asymmetry and mal-alignment

Treatment Interventions:
● Modalities
● Active Release Therapy/Graston
● Strain-Counterstrain
● SI joint manipulation

Treatment Interventions:
● Orthotics and heel lifts
● Shoes
● Core stabilization
● Stretching
● Aquajogging

Systematic reviews
– Modalities (ultrasound, electrical stimulation)
– Spinal manipulation
– ART/Graston
– Orthotics
– Stretching
– Core stabilization

Based on the scientific literature regarding

treatment interventions, what do chiropractors,
massage therapists, and physical therapists
continue to utilize?

Community Standards
Accepted Community Standards Of Care

(what providers and patients consider “acceptable”)
vs
Evidence-Based Standards Of Care
(clinical guidelines; outcomes-driven)

Problem
ACSC and EBSC are not the same!
ACSC has unfortunately become “gold

standard” with patients

Responsibility
We continue to tell payors that evidence and

outcomes are important …
We continue to tell legislators that evidence and

We continue to tell students that evidence and

Responsibility
We continue to tell patients that evidence and

Our professional association continues to

advocate it ...

But In The Words Of Gandhi ...
“We must be the change

we wish to see in the
world”

Challenge Your Thinking!
“We can't solve

problems by using the
same kind of thinking
we used when we
created them.”
(Einstein)

For More Information:
● Smart Sport International

www.smartsport.info
● Smart Life Institute
www.smartlifeinstitute.com
● “Consumer's Guide To Health”
Every second Tues at 8:00pm CT
www.blogtalkradio.com/abesselink
● “RunSmart: A Comprehensive Approach To
Injury-Free Running”
www.lulu.com/abesselink
Photo Credits
All photos Creative Commons (Attribution-No Derivative)
– #3, 14, 21, 28, 39, 94 “Evidence” on Flickr by billaday
– #8 “Counterstatement to what sean calls 'evidence'” on Flickr by astera
snowwhite
– #12 “Choose your evidence carefully” on Flickr by rocket ship
– #49 “Il y a 60 ans, Gandhi assassiné" on Flickr by ah zut
– #13, 51: Allan Besselink
– All others understood to be public domain/fair use and all attempts have
been made to identify all image owners and licenses

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The Injured Runner:

Allan Besselink, PT, Dip. MDT

● Physical therapist (1988)

Allan Besselink, PT, Dip. MDT 3

“The plural of anecdote is not data”

“In God we trust – all others bring data”

Allan Besselink, PT, Dip. MDT 4

“The conscientious, explicit, and judicious

Allan Besselink, PT, Dip. MDT 5

But, one problem exists -

– Evidence is of no use if it is not integrated and

Allan Besselink, PT, Dip. MDT 6

The impact of the provider's belief systems

Allan Besselink, PT, Dip. MDT 7

Allan Besselink, PT, Dip. MDT 8

“The inability to challenge our belief systems

Allan Besselink, PT, Dip. MDT 9

It is a very uncomfortable struggle to integrate

Allan Besselink, PT, Dip. MDT 10

“To arrive at a contradiction

Allan Besselink, PT, Dip. MDT 11

Allan Besselink, PT, Dip. MDT 12

Use the lessons learned

Allan Besselink, PT, Dip. MDT 13

Allan Besselink, PT, Dip. MDT 14

Allan Besselink, PT, Dip. MDT 15

Allan Besselink, PT, Dip. MDT 16

30+ years of scientific evidence would indicate:

No specific correlation between anatomic mal-

Allan Besselink, PT, Dip. MDT 17

Allan Besselink, PT, Dip. MDT 18

Allan Besselink, PT, Dip. MDT 19

What do patients continue to hear from doctors,

Allan Besselink, PT, Dip. MDT 20

Allan Besselink, PT, Dip. MDT 21

Perceived value of imaging in the assessment

Allan Besselink, PT, Dip. MDT 22

● Krampla WW, Newrkla SP, Kroener AH, Hruby WF.

Allan Besselink, PT, Dip. MDT 23

● Schueller-Weidekamm C, Schueller G, Uffmann M, Bader

Allan Besselink, PT, Dip. MDT 24

Allan Besselink, PT, Dip. MDT 25

● Lessons learned from back pain: 70% of

Allan Besselink, PT, Dip. MDT 26

What will physicians and chiropractors have the

Allan Besselink, PT, Dip. MDT 27

Allan Besselink, PT, Dip. MDT 28

Perceived value in the clinical reasoning

Three primary approaches:

Allan Besselink, PT, Dip. MDT 29

● Seffinger MA, Najm WI, Mishra SI, Adams A, Dickerson

Allan Besselink, PT, Dip. MDT 30

● Badii M, Shin S, Torreggiani WC, Jankovic B, Gustafson

Allan Besselink, PT, Dip. MDT 31

● Sturesson B, Selvik G, Udén A. Movements of the

Allan Besselink, PT, Dip. MDT 32

● Palpation-based assessment techniques are

Allan Besselink, PT, Dip. MDT 33

● Robinson HS, Brox JI, Robinson R, Bjelland E, Solem S,

Allan Besselink, PT, Dip. MDT 34

● Spratt KF, Weinstein JN, Lehmann TR, Woody J, Sayre H.

Allan Besselink, PT, Dip. MDT 35

● Werneke MW, Hart DL, Resnik L, Stratford PW, Reyes A.

Allan Besselink, PT, Dip. MDT 36