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Ironman Medical Conference 2012

Biomechanics of
Running and Injury

Daniel E. Lieberman
Human Evolutionary Biology

Peabody Museum, Harvard University

Funding disclosure:
Currently: None
In past: Vibram USA

This talk is Part 1 of a trio of lectures

Today
1. The problem of injury
2. Basic biomechanics of running & injury
3. Treating symptoms (palliative care)
vs preventing causes

Later Lectures
1. Barefoot running (pros, cons, unknowns)
2. The evolution of running

Ironman is a bit extreme by most peoples


standards
but we evolved to be
endurance athletes!
"

"Ironman360.com"

Why, if we evolved to be physically active


athletes, do so many athletes get injured?
Traumatic

Repetitive

"911bicycleinjurylaw.com"

Abnormal

Normal

Normal

>80% injuries = musculoskeletal

Standard hypotheses about


running injuries
1. Running/sports is intrinsically injurious

2. Injuries result from physical abnormalities


3. From running on hard, flat surfaces
4. Training errors

PROBLEMS WITH THIS FRAMEWORK:


Doesnt provide proximate (mechanistic) or
ultimate (why) explanation for most injuries
Not very predictive (why do some runners get
injured more/less?)
Not very useful for prevention

We can do better!
1. The problem
2. Basic biomechanics of running & injury
3. Treating symptoms (palliative care)
vs preventing causes

to begin:
BIOMECHANICAL DIFFERENCES
BETWEEN RUNNING & WALKING

Anatomy is the same; biomechanics are very different!

BASIC TERMINOLOGY
Stride = full cycle from heel strike (HS) to heel strike
STANCE PHASE
1. heel strike
2. foot flat
3. heel off
4. toe off
SWING PHASE

HS

FF.

HO

TO

SWING

WALKING
STANCE PHASE
8%

HS

FF

SWING PHASE
43%

HO

62%

100%

TO

In a walk, each foot is on the ground for more


than 50% of the stride

Walking: inverted pendulum model

Potential Kinetic
Energy Energy

Energy'

PotenKal"
energy"

KineKc"energy"

Ground'Reac,on'Force''
(%"body"mass)"

0""""""10"""""20"""""30"""""40""""""50"""""60"""""70""""""80"""""90""""100"
%"stride"cycle"
150"

Double""
support"

Single"support"

Double""
support"

100"
50"
0"

HS"

TO"

0""""""10"""""20"""""30"""""40""""""50"""""60"""""70""""""80"""""90""""100"
%"stride"cycle"

Biomechanical challenge:
move Center of Gravity (COG) forward
economically and with stability

COG: 2 cm anterior to 2nd sacral vertebra

5 cm

Oscillations of COG during


walking = distorted figure of 8

4.5 cm

Determinants of gait
#1
#4 #2,3

#2
#1

#5

#3

#4-5

Control of vertical
fluctuations of COG

WHAT ABOUT RUNNING?

Cost (Joules / meter)

Sprint

300
Endurance run

250
200
150

walk

100
50

Speed (m/s)

Running is a

gait

REALLY, RUNNING IS JUST JUMPING FROM ONE LEG TO THE OTHER

Aerial phase (in air)


Center of Gravity (COG)
in front of hip (falling)

Knee bent at foot strike


Knee bent during swing
Opposite arm swing

Running = very different mechanics:


MASS-SPRING MODEL

PE

KE

INVERTED PENDULUM

MASS-SPRING

mass-spring model
x

Potential energy stored, U = 0.5kx2


k= spring constant
X=displacement

Hence, energy exchange is different

PE

KE

INVERTED PENDULUM

MASS-SPRING

Kinetic
energy
Potential
energy HS

MS

TO

HS

MS

TO

Elastic
energy

During running the forces are:


1.Much higher
Heel strike
300
2.More rapid

Midstance

250
200

(% body mass)

Ground Reaction Force

walk

run

150

150

100

100

50

50

HS

TO

20

40

60

% stride cycle

80

0
100

HS

TO

HS

% stride cycle

TO

Let s look more closely

Midstance
(maximum elastic
energy storage)

Footstrike

(collision)

Toe off

(recoil)

There s a lot going on!


Another"
lecture!"

Speed (e.g., leg extension)


Economy (e.g., knee flexion during swing)
Stabilization (e.g., arm movements)
Force resistance (e.g., stiffness)

From an injury perspective,


four factors stand out:
1. Traumatic
2. Repetitive stress
(overuse)

1.
2.
3.
4.

Force magnitudes
Force rates
Force cycle number
Stabilization (falling)

}"}

energy
energy"

1.Traumatic injury:
sudden tissue damage, usually from high, rapid force
-Collisions
-Falls
-Concussions
-Sprained ankles
-Lacerations
-Broken bones
-Etc
-Muscle injury
-Tears, knots, spasms
-Tendon/ligament injury
-Tears
-Evulsions
-Etc..

and STUPIDITY!

2. Repetitive Stress (overuse) injury:


gradual tissue damage, usually from repeated forces

How and why do these happen?

Material properties
Force = mass acceleration (Newtons)

Stress () = force / area (Pascals)

Strain () = % change in length (L/L)


positive strain (+) is tension
negative strain (-) is compression

=Stress (F/A)*

Strength = resistance to failure (sometimes bending)


Stiffness = resistance to deformation
f

f
y

tic

plas

f = fracture
y = yield

y
x

= Strain (L/L)
*unit = Pascals (N/m2)

Stiffness, E = slope of stress vs strain (y/x)

AKA Modulus of Elasticity (or Young s modulus)

very stiff

Stress (F/A)

intermediate

very flexible

Strain (L/L)

Stress, , force/area

TRAUMATIC INJURIES: forces greater


than yield or fracture point!
plastic reg

ion

yield point

Strain, , L/L

fracture!

Bones: need to stay stiff & strong


Ligaments and tendons: need to be
springy & strong
Stress to generate plastic deformation: y
Stress to generate fracture: f

=Stress (F/A)

f
y

f
y
Weaker
Stiffer

Stronger
Less stiff

Strain (L/L)

f
y

Stiffer isn t
necessarily stronger!

KEY VARIABLES:
1.# of cycles to failure
2. strain rate
3. rate of loading

How do we prevent traumatic injuries?


1. Avoid applied forces (from fall, etc)

2. Increase tissue elasticity (warm-up, stretching, etc)

How do we prevent traumatic injuries?


3. Increase tissue strength (growth, density)
+ +
+
+
+
+
- - +
+
- - +
+
+
+ +

BUT MOSTLY IN YOUNG INDIVIDUALS!

How do we prevent traumatic injuries?


4. Repair tissues as they get damaged

Microfracture!
Example: bone remodeling

THEREFORE traumatic injury prevention:


Partly performance related:
1. Avoid excessive applied forces (falls & collisions)

Partly training related:


2. Increase tissue elasticity (warm-up, stretching, etc)
3. Increase tissue strength (growth, density)
4. Repair tissues as they get damaged

What about Repetitive Stress Injuries?


30-70% runners/year!
100
90

Injury rate (%)

80
70

Injury rates have


not declined in
30 years!

60
50
40
30
20
10
0
1980

1985

1990

1995

2000

2005

2010

Year of publication
van Gent et al.. Br."J."Sports"Med."41:469"(2007)

6 most common repetitive stress


injuries among runners:
Runners knee (patello-femoral pain syndrome)
Plantar fasciitis
Achilles tendinopathies
Shin splints/tibial stress
Iliotibial band syndrome
Lower back pain

MUCH HARDER TO
UNDERSTAND, PREVENT, & TREAT!

Repetitive stress injuries are caused


by repeated applied forces to
tissues that cause damage
Force ! Stress ! Strain ! Damage
f

f "

=Stress"(F/A)*"

y"

tic

plas

y
x

y"
"="Strain""(L/L)"

f"

=Stress"(F/A)*"

Microcrack!"

f "
y"

tic

plas

Pearson and Lieberman 2004


y

Hysteresis

y"

f"

"="Strain""(L/L)"

Wang and Gupta 2011

Repeated strains of high


magnitude and rate cause:
Fractures (micro & macro)

InammaKon"

Potentially injurious forces caused by


running
2. Internal forces

1. External Forces

Muscle/tendon
strains
FGRF"
Ground
Reaction
Forces

Fcalf"
rcalf"

Torques
rGRF"

IMPACT FORCES ARE A SPECIAL CONCERN


High: 1.5-3x body weight
Fast: = 80 bw/sec (shod)
= 500 bw/sec (barefoot)
Repetitive:
60 km/week = 2 million impacts/year!

BW

4
3
2
1
0
3.00
2.25
1.50
0.75
0.00

Vertical head
acceleration

SHOCK WAVE
7 milliseconds from ground to head

Ground
reaction force

Must be damped!

Many studies have found impact peaks are


major predictors of injury
Tibial stress syndrome
Milner et al 2006

Med Sci Sports Exer.

X
F

Runners knee
Pohl et al 2009 Clin J Sports Med

IT band syndrome
Achilles tendonitis
Back pain
Davis et al., 2010 ASB

Time

Irene Davis

What causes impact peak:

0Impact peak

Rapid exchange of
momentum between body
and ground
Saw-toothed force profile

Running form also affects torques


Got"a"moment?"

Ankle Torques
(external

&

internal)

FGRFrGRF = Fcalfrcalf
FGRF
Fcalf
rcalf

rGRF"

Which require
higher muscle
forces!

TORQUES/INTERNAL FORCES
are affected by
Shoes

Running form
(e.g. strike type)

Fv"

Fv"
Fcalf"
FGRF"

F l"

Kerrigan'et'al'(2009)'Phys'
Med'Rehab'1,'1058'

F l"

rcalf"

rGRF"
Lieberman,'White'and'Daoud,'
unpublished'data'

Dierent'strike'types:'tradeKo'between'ankle'&'knee'
Dorsiexor"
moment"

Ankle Torque, Shod RFS

Ankle Torque, BF FFS

0.1

0.10

0.05

0.05

0.00

-0.05

-0.05

-0.1

-0.10

-0.15

-0.15

-0.2

-0.20

-0.25

-0.25

-0.3

-0.30

-0.35

-0.35

-0.4

P<0.05"

-0.40
0

20

Plantarexor"
moment"
Extensorm
oment"

40

60

80

100

0.40

0.35

0.35

P<0.05"

0.30

0.25

0.20

0.20

0.15

0.15

0.10

0.10

0.05

0.05

0.00
-0.10

Flexor"
moment"

20

30

40

60

80

100

0.30

0.25

10

40

Knee Torque, BF FFS

Knee Torque, Shod RFS

0.40

-0.05 0

20

50

60

0.00
-0.05 0

10

20

30

40

50

60

-0.10

Lieberman,'White'and'Daoud,'unpublished'data'

Finally
1. The problem
2. Basic biomechanics of running & injury

3. Treating symptoms
vs
Preventing causes

The fundamental problem with our


general approach to medical care:
Too little prevention
&
Too much palliative medicine =
ease/control symptoms rather
than treat causes

How often do
athletes seek advice
to prevent injuries
BEFORE they get
injured?
How many health care providers have
the opportunity to practice preventative
medicine?
- preventative podiatry?
- preventative orthopedics?
- preventative physical therapy?

Do we know how
runners should run?
(what is good form?)
How many runners
learn good form?
How many health care providers consider
a runners form when treating injuries?

Biomechanics of running injuries


suggest 3 major ways to prevent them:
1. Adapt structures to bear loads
2. Improve sensory feedback to
prevent falls/collisions
3. Avoid repetitive impacts

Injury Prevention
1. Adapt structures to bear loads
Every structure in the body has its own
safety factor: = Maximum strength/
Most bones =
maximum load
1.4 4.1

SF = 6

SF = 11

Biewener"A"(1993)"Calc"Tiss"Int"53:"S68"

Why not design bodys structures with


adequate capacity?

Phenotypic plasticity: gene-environment


interactions allow organisms to adjust
phenotypic in response to environmental stimuli
1. Permits integration
2. Permits trade-offs: e.g. strength
vs cost
3. Permits more optimal adaptation
to environment

No pain, no gain is an
adaptation

Skeleton, however, mostly responds to


loads prior to adulthood
Bone: Exercise dose response curve
sedentary

BMD

young
old

immobilization

activity

loading/day

Heaney RP et al (2010) Peak bone mass. Osteoporosis Int 2000;11(12): 985-1009.

Why we need to get more kids


physically active:

Bilateral asymmetry* in mid-distal humerus of three tennis pros:


Sex/age of play
Cortical area
J (Polar SMA) <-- (Ixx+Iyy)
Female (8-14 years)
53.5
108.0
Female (15-30)
23.2
14.0
* ([playing arm-nonplaying arm]/nonplaying arm)100
Jones"et"al,"1977;"Ru"et"al.,"1994"

Reaction norm continuum:


"sciencephoto.com"

bone

Little
Slow

tendon/
ligament

muscle

Lots
Fast

Injury Prevention
2. Improve sensory feedback to
prevent falls/collisions

More"tomorrow"

Injury Prevention
3. Avoid repetitive impacts, and rapid torques
Barefoot heelstrike

On hard
surface =
Ouch!

Shod heelstrike

20 miles/week: 1.5
million impacts/year!

Forefoot strike

Less of a
problem!

Each heel strike generates an impact peak:

0-

Most common solution: lessen the problem!


1. Elastic heel lowers
stiffness, slowing rate of
loading (almost no effect on
magnitude of loading)

Impact peak

(7x slower in shoe)

Impact peaks in cushioned shoes:

Still shod thumpers get injured more often!


Achilles tendonitis
Tibial stress fractures
Milner et al 2006

Med Sci Sports Exer.

Runners knee

X
F

IT Band Syndrome
Pohl et al 2009 Clin J Sports Med

Time

Back pain
Davis et al., 2010 ASB

Irene Davis

Most common treatment: change running shoes


No evidence this has any effect!
Richards et al, 2009 Br J Sports Med
Ryan et al., 2010 Br J Sports Med
Knapick et al., 2010 Am J Sports Med

More expensive/cushioned
running shoes correlate with
higher injury rates
Marti et al, 1988 AmJ Sports Med 16: 285

But, not all strikes generate an impact peak!

Many barefoot runners tend to land gently ( softly )


often landing more on ball of foot or middle of foot
(forefoot)
(midfoot)

Hypothesis:
Impact peak free style of running
(forefoot striking) should lead to
lower injury rate than rearfoot
striking
Lower impacts
More gradual
torques

Evidence: Harvard Track Team Study


Injury rates (per 10,000 miles)

2.3x!"

>"
7.8 .48
Forefoot strikers
N=8

16.4 .64
Rearfoot strikers
N=20
Daoud,'et'al'(2012)'MSSE'

In short
All injuries have a biomechanical basis
Some runners may be more prone to injury from
-weakness/insufficient adaptation
-training errors
-poor form
Considering the biomechanical bases for injury
may help us prevent injuries before they happen
Running form is a far more important factor for
preventing injuries than has been previously
recognized.

BUT
WHAT IS GOOD
FORM?

Next lecture!