What to do with an LLD Once the assessing clinician has arrived at the conclusion that a leg length discrepancy is present, they must decide what intervention, if any, is warranted. At present, “there is a lack of robust evidence on which to base the decision to initiate treatment of leg length discrepancy” (Vogt et al., 2020). Recommendations from Vogt et al. (2020) are not to treat an LLD that is less than 1 cm. For LLDs greater than 1 cm, they recommend reducing it to 1 cm via conservative means (heel lift). Age is an important consideration when considering treatment for an LLD. For runners who are not skeletally mature, we are getting a glimpse in time of their leg lengths. It is impossible to know how skeletal growth may affect leg lengths in the future, so clinicians need to be very careful with correction. For runners who are skeletally
mature, their body has already likely made musculoskeletal adaptations to a difference in leg length, and attempting to correct their LLD might cause more problems than it solves. A study by Cahanin et al. (2019) looked at the effect of correcting a difference in iliac crest height of less than 9 mm in three recreational runners with lower extremity pain related to running. One subject did not experience any help from the LLD correction, and the other two trended toward increased pain. They concluded that correction of a small LLD may be unnecessary and potentially harmful. In summary, when evaluating and treating runners, assessing clinicians should carefully determine whether an LLD is present and judiciously decide whether treatment is warranted.
SPECIFIC RUNNING INJURIES
The most common injuries in non-ultramarathon runners are Achilles tendinopathy, medial tibial stress syndrome, patellofemoral pain syndrome, plantar fasciitis, and iliotibial band syndrome. For ultramarathoners, the top three injuries are anterior compartment tendinopathy, patellofemoral Plantar fasciitis The plantar fascia is a dense connective tissue structure that runs from the medial tubercle of the calcaneus to the metatarsal heads. It functions to support the longitudinal arch of the foot. It stabilizes the metatarsal heads during propulsion and assists with force absorption during the loading phase of gait. According to Charles et al. (2023), limited dorsiflexion and a high body mass index are the most common risk factors for developing plantar fasciitis. Foot alignment Over-pronation Because of its span along the bottom of the foot, excessive pronation can lead to lengthening or stretching of the plantar fascia, which can contribute to onset of plantar fasciitis. Elongation of the plantar fascia also inhibits optimal function of the windlass mechanism (described under “Windlass Test”) and inefficient propulsion during running (Boob et al., 2023). Under-pronation Pes cavus describes a foot with a high arch, a condition that is frequently accompanied by under-pronation. Pronation plays a major role in shock absorption during running, so under-pronation results in poor force distribution and, consequently, increased stress to the foot/plantar fascia. Symptoms Patients with plantar fasciitis will experience pain on the plantar surface of the medial heel. This pain is most noticeable with the initial steps after inactivity. For example, the first steps when getting up in the morning are typically painful. Prolonged weight bearing can also increase symptoms (standing, walking, running). Onset of symptoms is usually related to an increase in activity such as starting a running program or increasing the length and/or intensity of running workouts (Koc et al., 2023). Physical examination Palpation will elicit tenderness at the medial insertion of the plantar fascia at the medial calcanceal tubercle in patients with plantar fasciitis. Active and passive limitations in ankle dorsiflexion are common and assessment of range of motion into dorsiflexion with the knee both flexed and extended should be completed. Plantarflexion, supination/eversion, pronation/inversion, and great toe extension range of motion should be assessed (Koc et al., 2023).
pain syndrome, and Achilles tendinopathy (Kakouris et al., 2021). This section will look at common running injuries, considering contributing factors and outlining evidence- based treatment.
Manual muscle testing of the anterior tibialis, posterior tibialis, fibularis longus and brevis, gastroc-soleus, and flexor hallucis longus should be done to assess their strength as these are important contributors to lower leg and foot function (Koc et al., 2023). Windlass mechanism refers to the tightening of the plantar fascia that occurs when the great toe is extended, such as happens during running when weightbearing shifts to the metatarsal heads during propulsion. This windlass mechanism works to elevate the longitudinal arch by shortening the distance between the calcaneus and the metatarsal heads (Windlass test, 2021). This test can be performed in both a weightbearing and non-weightbearing position. For the non-weightbearing test, the patient sits in supine with the knee extended. The examiner stabilizes the foot with one hand by grasping just behind the first metatarsal head. The other hand is used to extend the great toe. The interphalangeal joint of the great toe should be allowed to flex to eliminate the influence of a short flexor hallucis brevis. The test is positive if it provokes pain (Windlass Test, 2021). Special tests Windlass test To do the windlass test in weightbearing, the patient stands on a stepping stool with equal weight on both feet and the metatarsal heads just over the edge of the step. Again, the examiner passively extends the great toe while allowing the interphalangeal (IP) joint to flex. The test is positive if it provokes pain (Windlass Test, 2021). Treatment Treatment for plantar fasciitis is dictated by the causative factors identified in evaluation. Training As with all running injuries, the examiner should question the client about recent changes in their running regime including changes in training volume, running surface, and shoes.
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