Impingement the Runner’s Trap
Most runners are aware that there are certain injuries that can be expected from a lifestyle that includes regular running. Many times we begin to experience symptoms from injuries we cannot remember happening. This is often the case with impingement.
What is runner’s impingement?
Impingement is defined by the Dictionary of Sport and Exercise Science and Medicine by Churchill Livingstone as, “A term used in sports medicine, when soft tissue is trapped, usually between bones, leading to pressure, inflammation, pain and loss of function.”
The following is a breakdown of types of impingement frequently associated with running. It is important to know what to look for and be properly diagnosed and treated as some cases of impingement as noted above, can lead to loss of function.
Hip impingement- Also known as Femoroacetabular impingement (FAI) – Runners experiencing pain in the groin area when running, jumping or sitting for long periods of time may be experiencing hip impingement. According to the Mayo Clinic, “hip impingement occurs when the ball and socket of the hip joint don’t fit together properly. The restricted motion damages cartilage and can cause pain … ”
Femoroacetabular impingement or hip impingement can include CAM impingement and Pincer Impingement as pictured below or, most commonly, a combination of the two.
According to the Children’s Hospital of Colorado, here’s the difference between the two:
CAM Impingement: Regarding deformities of the Femur. Cam impingement involves a deformity of the thigh bone. When the femoral head is abnormally shaped and the head and neck junction run into the hip socket during certain activities such as sitting for long periods of time, bending over, or riding a bike, CAM Impingement can occur.
Pincer Impingement:Regarding deformities of the Socket. When contact is made between the femoral head-neck junction and the acetabular rim, Pincer Impingement can occur.
Symptoms to watch for
- pain in the groin area during or after flexing the hip
- Difficulty flexing your hip beyond a right angle.
- Clicking or popping of the hip
- Difficulty sitting for extended periods of time
Causes of Hip Impingement
As discussed, the root cause of Hip Impingement is caused by the abnormal relationship between the ball and socket in the hip which is an internal development. According to the Nirschl Orthopedic Center, “FAI usually presents as groin pain with activities or with hip motion. Sometimes, patients with FAI can recall a single traumatic event which they note as the cause of their symptoms, but often the onset is more insidious… Because athletically active people may work the hip joint more vigorously, they may begin to experience pain earlier than those who are less active. However, exercise itself does not cause FAI”.
Risk Factors Associated With Hip Impingement
Common activities that work the hip joints vigorously can increase the symptoms of Hip Impingement. According to the Nirschl Orthopedic Center, these activities include:
- Activities which require vigorous movement such as Ice Hockey, Soccer, Lacrosse, Martial Arts, Yoga, ect..
- Riding a bicycle
- Powerlifting or other activities which involve deep squatting
- Sports which include rowing
- Being in a deep-seated position for extended periods of time
The basis for a diagnosis of this condition will be a thorough physical examination. During this examination, an actual impingement test is likely to be performed.
- Inspection of hips
- A feeling of bone landmarks and muscles
- A range of motion (flexion, extension, abduction, adduction, internal and external rotation)
- Passive, active and rested testing involves the examiner or the patient moving the hip or resisting motion to test the muscle strength
- Patrick (FABER) test- Patient is tested for pain when in a position with the ankle above the opposite knee
- FADIR test- Patient is tested for pain when the knee is bent and crossed over the body and the heel of the bent leg is pulled in the opposite direction
- Log roll- examiner rolls the leg back and forth with patient laying on their back
- Patient hops on the involved leg
- Examination of lower back, abdomen, and pelvis
In addition to this other tests may be performed. Further testing may include:
- Radiography (X-rays) which produce two-dimensional images of the hip joint
- Magnetic resonance imaging (MRI) which produces a three-dimensional image including soft tissue cartilage and labrum)
- Computed tomography (CT) scan which takes a series of small images at different angles and then applies a computer algorithm to construct a three-dimensional image of the hip. A CT scan is often used to show doctors the detailed structure of joints.
- Decreasing physical activity that causes symptoms- Depending on the severity of your symptoms, your doctor may recommend that you reduce your amount of physical activity. If symptoms do not persist, this may be the best form of treatment for the time being.
- Anti-inflammatory Medication- If symptoms are not too severe, a prescription anti-inflammatory or NSAID may be enough to manage symptoms
- Physical therapy- An alternative to surgical correction of Hip Impingement may be physical therapy. Certain exercises can increase the range of motion in the hip and strengthen the muscles that support it. The increased support can relieve pressure and ideally relieve symptoms of FAI.
- Surgical treatment- When surgery is necessary to relieve the patient from their symptoms, a procedure called Arthroscopy can be performed.
The surgeon uses a small camera, called an arthroscope, to view inside the hip. During arthroscopy, your doctor will repair damage to the articular cartilage. The doctor may also fix Hip Impingement by trimming a certain part of the
acetabulum or removing a bump on the femoral head. In more severe cases of Hip Impingement, an open operation may be necessary. This will involve a larger incision.
Because of the abnormal development of the bones, there is no preventative measure that can be taken to avoid Hip Impingement. However, symptoms can be prevented by keeping the body at an ideal weight. Obesity will lead to increased pressure on all of the body’s joints but for somebody dealing with Hip Impingement, the increased pressure on the hip joints will be particularly problematic.
False Positives Associated With Hip Impingement:
Because it begins to develop in the very early stages of life, it can be hard not to confuse hip impingement with other conditions which are another reason that proper examination and diagnosis is crucial. The Nirschl Center describes the following conditions as those that might be confused with Hip Impingement;
- Pelvic Pain
- Pain in the Lower Back
- Pinched Nerve in the lower back
- Hip Dysplasia
- Pain in the Outside of the Hip
- Pain in the Back of the Hip
- Illness Related to Stress
- Pain or Inflammation in the Hip Flexor
- Pulled Groin
- Strained Abdominal Muscle (Sports Hernia)
- Pain in the Front of the Pelvis
- Pulled Quadriceps
Another type of impingement frequently associated with running is shoulder impingement or subacromial impingement.
Shoulder impingement- Subacromial impingement syndrome (SAIS) is the most common disorder of shoulder. SAIS encompasses several damages to the shoulder including rotator cuff tears, rotator cuff tendinosis, calcific tendinitis, and subacromial bursitis.
It sounds complicated but shoulder impingement can be basically explained as the tendons in the shoulder becoming trapped or pinched in the space beneath the acromion (a bone in the shoulder blade.) Which is why this condition is also known as trapped tendon syndrome.
Symptoms of Shoulder Impingement
- Sharp pain after any incident no matter how minor
- Difficulty reaching the arm behind the back
- Loss of function or strength
- Pain becomes more constant and is often worse at night
*According to The Steadman Clinic, “Pain usually increases at night for two reasons. First, inflammation and swelling tend to get worse as the shoulder is used during the day, and this can lead to more pain in the evening. Second, the mind is usually less occupied in the evening, allowing pain to become a major focus of attention.”
Causes of Shoulder Impingement
Although it is more commonly caused by activities which include raising the arm over the head, (such as swimming or baseball) shoulder impingement can also be associated with running due to the constant jostling and back and forth motion of the shoulder. When the rotator cuff continuously makes contact with the Acromion, the rotator cuff becomes swollen and is trapped or pinched under the Acromion. Less commonly, this can also be caused by trauma from impact such as a fall.
Risk Factors Associated With Shoulder Impingement
the four main risk factors associated with Impingement Syndrome include smoking, sleeping position, acromion shape, and occupation.
- Smoking- Participants who smoked, in the study performed by Tangtrakulwanichand Kapkird had 7 times the risk of suffering from shoulder impingement syndrome. This could be related to the effects nicotine has on tendon functioning as well as the effect on the tendon’s ability to heal.
- Sleeping position- This study showed that participants who slept predominantly on their side were also at a higher risk of suffering shoulder impingement syndrome. This is due to the fact that the weight of the body is applying pressure to the shoulder and as a result causes strain on the tendons of the shoulder.
- Acromion shape- This refers to the shape of the bone in the shoulder. There are three classifications of this bone.
- Convex (upturned)
In the study performed by Tangtrakulwanich and Kapkird, those with a hooked shaped Acromion tended to have a higher risk of Shoulder Impingement, although no study has been done to test this claim specifically. “…Such studies have reported, for instance, a higher incidence of rotator cuff problems in a hook type acromion without statistical analysis. Our study did confirm this earlier observation”
- Occupation- People with occupations requiring them to frequently reach overhead are also at a higher risk of suffering Shoulder Impingement. “Repeated use in the abducted position of the shoulder during work might cause repetitive trauma to rotator cuff musculature”
Diagnosis of Shoulder Impingement
The diagnostic process for this shoulder impingement is similar to the diagnostic process for hip impingement. Possibilities for diagnosis include;
- Thorough physical examination- Your medical history will be discussed and the doctor will examine your neck to rule out a pinched nerve. Arm strength and range of motion will also be tested in this examination.
- X-rays- An x-ray can be performed to look for a bone spur on the Acromion which can be the cause of shoulder impingement.
- Magnetic Resonance Imaging (MRI) or Ultrasound- unlike the X-ray, an ultrasound or MRI can show soft tissue damage such as fluid and inflammation.
- Reducing physical activities which include reaching overhead
- Anti-Inflammatory medication such as NSAIDs
- Physical therapy
- Steroid injections- If other methods of pain relief are ineffective, a cortisone shot may be administered to the Bursa (which is below the Acromion). Cortisone is a highly effective anti-inflammatory
- Arthroscopic- As discussed above as a treatment option for Hip Impingement, Arthroscopic surgery can be performed by creating small puncture wounds around the shoulder. The doctor will use a small fiber optic scope attached to a camera to examine the shoulder and will remove any bone or soft tissue causing the impingement.
- Open Surgical Technique- This technique will include an actual incision where the doctor will be able to see directly what is causing the impingement and remove it accordingly.
Rehabilitation from Methods of Treatment- Recovering from shoulder impingement surgery can take anywhere from 2 months to one year depending on the type of surgery and severity of the condition. Rehabilitation will include allowing the shoulder to heal in a sling and will typically be followed by physical therapy.
Unlike Hip Impingement that is mostly not preventable, there are certain measures one can take to ensure they do not develop shoulder impingement. Prevention, for the most part, includes increasing the support of the shoulder itself. This includes increasing strength and flexibility of the muscles around the rotator cuff. The following stretches and exercises can be used to prevent shoulder impingement;
Scapular Push Up
- Begin by laying on your stomach.
- Prop up on your elbows.
- Let your upper back and shoulder blades sag down and come together.
- Push through your elbows and round out your upper back as much as you can and hold.
External rotation lying
- Begin by laying on your side with the affected arm on top.
- The upper arm should be resting on your side and the elbow bent so that the hand points towards the floor.
- Rotate the shoulder so that the hand moves up, towards the ceiling as far as possible.
- Slowly return to the starting position.
- Start with a light weight of around 5 lbs.
- Aim for 10 to 20 repetitions.
External rotation in abduction
- Begin by stands with the arm raised to the side at a 90-degree angle (the arm should be parallel to the floor).
- The elbow can also be rested on a chair or bench (in a seated position).
- The elbow should also be bent to 90 degrees.
- Using the elbow as a fixed point, rotate the shoulder so that the hand points upward.
- Slowly return to the starting position.
- Start with weight around 5 lbs or use a resistance band.
- Aim for 10-20 repetition initially.
False Positives Associated With Shoulder Impingement
The most prominent false positive associated with shoulder impingement is rotator cuff tendinopathy. Consultant Physiotherapist, John Miller describes tendinopathy;
“(Tendonitis) actually means “inflammation of the tendon,” but inflammation is actually normal tendon healing response which can cause some tendon pain. This is known as the reactive phase …
The reactive phase is when tendinopathies quickly deteriorate and move to a phase known as the degenerative phase. This is when the collagen in the tendon begins to degenerate because of consistent overuse. Because of this degeneration, anti-inflammatory treatments are not known to be effective. Therefore these tendinopathies are best treated with functional rehabilitation. The best results occur with early diagnosis and intervention.”
Rotator Cuff Tendinopathy can easily be confused with shoulder impingement syndrome due to the similarities in symptoms. However, tendinopathy in any area of the body (not just the shoulder) will not respond well to anti-inflammatory, which is one of the most effective treatments for shoulder impingement.
When two or more bones in the foot do not connect in a normal fashion, it is called Tarsal Coalition. This condition affects the Tarsal bones in the back of the foot and in the heel. The result of this abnormal connection can be a severe flatfoot.
A simple breakdown of this condition is that two bones in the feet fuse together over time. This condition occurs most often in infants or during fetal development while the bones are not yet solidified. As bones in the feet mature and harden, the bones fuse together.
Symptoms of Tarsal Coalition to watch for
Because this condition develops over time, as the bones in the feet harden, a person may go many years with no symptoms or without realizing there is a problem. When symptoms do become noticeable, they may appear in the following ways;
- Pain after regular activity
- Stiffness in the foot or feet after regular activity
- Pain increases with an increase in activity
- Trouble walking on uneven surfaces
Causes of Tarsal Coalition
Similar to hip impingement, Tarsal Coalition begins with fetal development. This can be due to genetic error, infection or trauma. Also according to Boston Children’s Hospital, a child is more likely to have tarsal colitis if one (or both) parents have had it.
Risk Factors Associated With Tarsal Coalition
This condition that is mainly caused by gene mutation during fetal development. No genetic testing for this condition is available at this time. Presently the only risk factor is a genetic predisposition. However, risk factors when considering the symptoms of Tarsal Coalition include those who are suffering from arthritis.
Diagnosis of Tarsal Coalition
When symptoms of Tarsal Coalition finally do appear, there are several steps that can be taken to diagnose this condition accurately. Steps for diagnosis include;
- Physical Examination- Your doctor will go over your medical history then will perform a thorough examination. This can include an examination of the gait and flexibility of the foot.
- X-rays- Because Tarsal Coalition is a fusing of the bones, it should be visible to your doctor through the use of x-rays.
- CT scans (Computed tomography scans) – This method of diagnosis will likely be preferred because it provides greater visible detail when compared to x-rays.
- MRI scans (Magnetic Resonance Scans) – This method of diagnosis provides imaging of soft tissues and cartilage. It may be ordered by your doctor in an attempt to locate any developing fusions with soft tissue and cartilage.
Treatment of Tarsal Coalition
There are several levels of treatment for Tarsal Coalition depending on the severity of the symptoms associated with the condition. The American Academy of Orthopedic Surgeons describes treatment possibilities in the following;
- Taking a break from high-impact activity for a period time — 3 to 6 weeks — can reduce stress on the tarsal bones and relieve pain.
- Arch supports and other types of orthotics for the foot and to relieve pain.
- Temporary boot or cast. These options can immobilize the foot and take stress off of the tarsal bones.
- Steroid medications may be used in conjunction with other nonsurgical options to provide temporary pain relief.
- In this procedure, the coalition is removed and replaced with muscle or fatty tissue from another area of the body. This is the most common surgery for the tarsal coalition because it preserves normal foot motion and successfully relieves symptoms in most patients who do not have signs of arthritis.
- Larger issues that can cause changes and also involve arthritis may be treated with joint fusion. The goal is to stabilize painful joints and place the bones in the proper position. Infusion for a tarsal coalition, the bones may be held in place with large screws, pins, or screw-and-plate devices.
Nothing can be done to prevent Tarsal Coalition but symptoms can be prevented by keeping an optimal body weight and not overusing the affected foot with vigorous activities.
False Positives Associated With Tarsal Coalition
Because the pain is reported to be similar, a Tarsal coalition can be confused with inflammatory arthritis or rheumatoid arthritis.
Sinus Tarsi Syndrome
Sinus Tarsi Syndrome is a clinical disorder characterized by specific symptoms and signs localized to the sinus tarsi (known as the “eye of the foot”), which refers to an opening on the outside of the foot between the ankle and heel bone. (Richard Bouché, D.P.M.)
Symptoms of Sinus Tarsi Syndrome to watch for
- Difficulty bearing weight on the affected foot
Causes of Sinus Tarsi Syndrome
Very commonly, running will be done on the uneven ground. This contributes to many of the conditions covered in this article. However, running on uneven ground is by far the most common cause of Sinus Tarsi Syndrome. This is because when a runner roles their ankle, the swelling that occurs causes the tissue to become compressed. This results in a pinching sensation in this area of the foot. Less commonly, this condition can be caused by the rolling in of the foot. When the foot is rolled in or pronated, pressure is applied causing the same pinching sensation in this area.
Risk Factors Associated With Sinus Tarsi Syndrome
- Running on uneven ground, gravel, wet grass, hills
- Muscle weakness
- Improper footwear
- Lack of flexibility
Diagnosis of Sinus Tarsi Syndrome
To diagnose Sinus Tarsi Syndrome your doctor may use the following procedures;
- Physical Examination- Physicians will examine the strength of the muscle in the ankle by performing resistance tests. They will also look for hypermobility in the ankle and examine the range of motion of the ankle.
- CT scans (Computed tomography scans) – This method of diagnosis can be used to rule out any fractured bones in the foot or ankle.
- MRI scans (Magnetic Resonance Scans) – This method of diagnosis will likely be preferred, “Magnetic resonance imaging (MRI) is the best method to visualize the structure within the sinus tarsi, especially the interosseous and cervical ligaments. The MRI findings may also include alterations in the structure of the interosseous and cervical ligaments and degenerative changes in the subtalar joint”
Treatment of Sinus Tarsi Syndrome
In most cases, non-surgical treatment will be effective.
but in some, more extensive cases surgery may be necessary. Your doctor may recommend one or several non-surgical methods of treatment before resorting to surgery. Treatment for Sinus Tarsi syndrome can consist of one or more of the following;
- stable shoes
- period of immobilization,
- ankle sleeve
- oral steroids
- steroid injections
- Arthroscopic Surgery
- Open Surgery
Treatment in the form of physical therapy is very common because in some cases Sinus Tarsi Syndrome can be treated completely through physical therapy alone. Other times physical therapy will follow surgeries or be used in tandem with some of the above listed treatment options. Physio-Advisor describes some methods of physical therapy;
- soft tissue massage
- electrotherapy (e.g. ultrasound)
- anti-inflammatory advice
- joint mobilization
- the use of crutches
- ice or heat treatment
- exercises to improve strength, flexibility and balance
- activity modification advice
- biomechanical correction
- footwear advice
- a gradual return to activity program
Prevention of Sinus Tarsi Syndrome
Prevention of Sinus Tarsi Syndrome is really quite simple and can be done by taking the following precautions;
- Wearing proper footwear
- Strengthening muscles in the feet and ankles
- Stretching- The following stretches can increase flexibility to the foot and ankle, thus reducing the risk of developing Sinus Tarsi Syndrome;
- Begin by being seated
- Cross affected ankle over top of the opposite leg at the knee
- On the affected ankle, hold one hand just above the ankle with one hand and hold the same foot with the other hand
- Pull the foot upward until a stretch is felt along the outside of the ankle
- Hold for 10 seconds and repeat 5 times
- Begin by lying face up
- Point the toes on the affected foot
- Bring toes back towards the body and flex upward
- Hold for 2 seconds in each position
- Repeat this motion 20 times on the affected ankle
Aggressive Plantar Flexor Stretch
- Begin by sitting on your heels on a table
- Sit in the middle of your foot off of the edge of a table
- Slowly begin to sit back on your heels
- Push your foot down (stretching the front of the ankle)
- Hold for 10 seconds and repeat 3 times
- As you progress, move your foot farther onto the table to intensify the stretch
To Sum It Up
Runners have to be very in tune with their bodies. We are typically aware of anything that doesn’t quite feel right immediately. However,
several of the conditions related to Runner’s Impingement, which are addressed in this article, happen without the runner even knowing there is something wrong. The point is to avoid injury to the best of your ability by taking preventative measures, take each symptom seriously and pay attention to your body and anything out of the norm. More often than not, injuries can be avoided. Symptoms associated with pre-existing conditions such as Hip Impingement and Tarsal Coalition can typically be managed without resorting to surgery by resting, anti-inflammatories or physical therapy.
In the event that surgery is necessary, most cases can be corrected and healing can be complete, typically, within a year. With proper diagnosis and treatment, these conditions may be able to be managed in a way that prevents the runner from losing function of the affected area. Final take away? Don’t ignore what your body is trying to tell you!
Disclaimer: This article is composed using information gathered from reputable and reliable sources but is not intended to take the place of professional medical advice. Please consult a physician if you are experiencing any physical symptoms.
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