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Author P. W. Kong
Affiliation Department of Kinesiology, University of Texas at El Paso, El Paso, Texas, United States
isometric [18]. It is, however, difficult to identify the exact mo- months after the injury, the subject continued to experience mi-
ment of injury or muscle length from regular video footage nor pain while walking for extended time periods.
which is typically sampled at a low frequency and from which
joint positions can only be roughly estimated. Data analysis
In light of understanding the mechanism of acute traumatic run- The following data of the injured trial and the five preceding
ning injuries, this case report presented data on running speed, noninjured trials were analyzed:
external forces, joint angles, joint moments, joint powers and
muscle-tendon complex length of the injured trial as well as Ground reaction forces
those of five preceding noninjured trials. It was hypothesized All GRF data were low-pass filtered at 100 Hz using a 4th order
that the injured trial would display indifferent kinetic and kine- zero lag Butterworth filter and normalized to the subject’s body
matic characteristics compared to the noninjured trials, and that weight. From the GRF data, touchdown and toe-off were identi-
these characteristics would allow the identification of the cause fied and stance time was calculated. Loading rates from touch-
of injury and the timing of injury occurrence. down to the peak force was computed by differentiating the
force-time histories of the vertical, anteroposterior and medio-
lateral GRFs. l" Fig. 1 illustrates 10 temporal and force variables
Material and Methods at critical moments of the stance phase and these variables were
! further analyzed. Each trial was time normalized to 100 % stance
Subject time to facilitate comparison between trials.
The subject was a male kinesiology major student (age = 37 yrs,
height = 1.69 m, mass = 91.0 kg) who was free from recent low- Running speed
er-extremity injury or pain. The experimental procedures the Running speed was calculated from the center of mass position
subject was participating in were approved by the institutional in the anteroposterior direction at touchdown and five frames
review board. Informed consent was obtained prior to experi- prior to touchdown onto the force platform.
mental procedures. After the injury happened, the subject
agreed to have his data published in this case report. Joint angles
Joint angle time histories were low-pass filtered at 13 Hz using a
Protocol 4th order zero-lag Butterworth filter. Sagittal plane angles of the
The subject ran at a self-selected speed across a force platform right hip, knee and ankle, together with the frontal plane rear-
(Advanced Mechanical Technology Inc., Model OR6-6 – 2000, foot angle, were analyzed. All joint angle data were time normal-
Watertown, MA, USA) while ground reaction force (GRF) data ized to 100% stance phase and were expressed in reference to an
were measured at 2400 Hz. In order to obtain kinematic data, anatomical position such that a positive angle referred to one of
31 reflective markers were placed on the subject based on the the following: (i) hip flexion, (iii) knee flexion, (iii) ankle dorsi-
Plug-in-Gait marker set and the running trials were recorded at flexion, and (iv) ankle inversion. The sagittal plane joint angle
240 Hz using an eight-camera motion analysis system (Vicon, variables of interest included the angle at touchdown for each
Centennial, CO, USA). The footwear used in the study was a joint, maximum hip flexion, maximum knee flexion and maxi-
light-weight cushioning shoe model (SpiraTM Clarion, El Paso, mum ankle dorsiflexion. Further, the joint angles at maximum
USA). In the original protocol, the subject was asked to run 10 joint moment and joint power (described below) were also iden-
times across the force platform located in the middle of a 20-m tified.
runway at his own pace. A successful contact was defined as the
subject’s right foot striking the force platform without altering Joint moments
his running technique. Sufficient time was given for familiariza- Sagittal plane joint moments at the hip, knee and ankle calcu-
tion before data collection started. lated using the Vicon Plug-in-Gait model in the Workstation
software were used to estimate internal joint loads. This com-
The injury mercial 3D model was based on previous studies including stud-
The subject completed five successful trials consecutively. On ies by Davis and colleagues [3] and Kadaba and coworkers [9].
the sixth trial, the subject sustained an injury on his right lower Details of the model and reduction technique are described else-
leg while making contact with the force platform. The subject where (www.vicon.com). All joint moment data were time nor-
explained that upon landing on the force platform, he felt a malized to 100 % stance phase. Positive moments referred to ex-
“snap” in his calf. Immediately after the injury, the subject expe- tension moments at the hip and the knee, and plantarflexion
rienced difficulty in ankle dorsiflexion and felt extreme pain in moment at the ankle. The moment at touchdown and maximum
his calf when he attempted to walk. The following day, a certified extension moment at each joint were identified.
physical therapist evaluated the subject’s injury as a partial tear
of the medial gastrocnemius and advised him to treat it with Joint powers
rest, ice, compression and elevation. This assessment was based Sagittal plane joint powers at the hip, knee and ankle were cal-
on the fact that the subject experienced sharp pain in the medial culated from the joint moment and angular velocity time histor-
calf, showed marked weakness in force production but was still ies. All joint power data were time normalized to 100% stance
able to produce movement. Initially, the subject received various phase. Maximum powers for energy absorption (negative) and
modality treatments including hot/cold packs, ultrasound and energy generation (positive) and their corresponding time of oc-
gentle stretching three times per week and was on crutches for currence at each joint were identified.
approximately 20 days. Once the pain diminished, he performed
strengthening and stretching exercise and began to resume
strength in about six weeks. In a follow-up approximately two
Results
!
Good consistency can be seen in GRF (l " Fig. 2) and joint angles,
moments and power (l " Fig. 3) among the five noninjured trials.
During the injured trial, the subject ran faster than the nonin-
jured trials. The injured trial was also characterized by a higher
peak vertical impact force, braking force, peak loading rate in
both braking and lateral forces (l " Table 1), and an unusual dou-
fered between the injured and noninjured trials for all three
joints (l " Table 2) while higher joint moment and power vari-
ables were mainly observed at the hip and the knee (l " Table 3).
Fig. 3 Sagittal plane joint angles, moments and powers of the hip, knee flexion or ankle dorsiflexion. Positive moments refer to hip extension, knee
and ankle angles during the stance phase of the injured trial (solid line) and extension or ankle plantarflexion moments. Positive powers refer to energy
five noninjured trials (dotted lines). Positive angles refer to hip flexion, knee generation; negative powers refer to energy absorption.
studies suggest that running injuries are not associated with rel- cause mileage has been consistently shown to be associated
ative body weight [15, 23]. One prospective study showed that a with running injuries [14,15, 24].
BMI greater than or equal to 26 kg • m–2 put men at a lower risk of
running injuries [21] although it is unclear how much mileage Running speed
was accumulated over the observed period. Thus, the relation- The subject was recreationally active and had systematic run-
ship between weight and running injuries seems unclear be- ning training when he was attending high school. However, at
the time of the present study, he did not run regularly. While
Data are in degrees and are expressed as mean (SD). qtd = angle at touchdown, qmax = maximum angle, qMmax = angle at maximum moment, qPabs = angle at maximum power for
energy absorption, qPgen = angle at maximum power for energy generation, N = noninjured trials, I = injured trial
Table 3 Sagittal plane joint moment and joint power variables at critical events
Joint Mtd (Nm) Mmax (Nm) Pabs (W) tPabs (ms) Pgen (W) tPgen (ms)
Hip N 102 (36) 127 (8) – 425 (76) 31 (39) 705 (165) 169 (11)
I 28 227 – 751 17 283 50
Knee N – 51 (17) 186 (15) – 1215 (220) 56 (6) 485 (78) 127 (18)
I – 38 142 – 758 67 657 33
Ankle N – 2 (4) 264 (6) – 971 (69) 78 (10) 2374 (250) 173 (10)
I 8 177 – 788 83 1078 167
Data are expressed as mean (SD). Mtd = moment at touchdown, Mmax = maximum extension moment, Pabs = maximum power for energy absorption, tPabs = time from touchdown
to Pabs, Pgen = maximum power for energy generation, tPgen = time from touchdown to Pgen, N = noninjured trials, I = injured trial. Positive moment = hip extension, knee extension
and ankle plantarflexion moment
During the injured trial, there was increased hip flexion and to attenuate impact shock, which may have an influence on
higher hip extension moment. Previous research has demon- causing the injury.
strated that biarticular muscles act to transfer power from prox-
imal to distal joint during explosive leg extension [8]. With the Timing of injury occurrence
foot fixed on the ground, an increase in hip flexion could induce The experimental data were in agreement with the subject’s de-
knee extension movement which may explain the reduced knee scription that the injury happened soon after he made contact on
flexion observed during the injured trial. This, in turn, may lead the force platform because all distinct kinetic and kinematic
to the stretch of gastrocnemius muscle. The knee action trans- characteristics appeared to occur within the early 35% of the
ferred from hip flexion may also be influenced by the length of stance phase. Once the subject realized the injury, he adjusted
the hamstrings, though the flexibility of the subject was un- his gait pattern which could be reflected by altered running me-
known. chanics towards the end of the stance phase. These adjustments
include a lower propulsive force during push-off, reduced knee
Shock attenuation extension and reduced plantar-flexion, moment and power at
Within the early stance phase before 35% of stance time, there the ankle during the late stance phase.
were higher peak forces and loading rates in the injured trial. In another case report which documented a torn gastrocnemius,
The increase in peak vertical impact force and peak braking force the injury was thought to occur during the push-off phase [18].
was probably related to the faster running speed of the injured This raised the question whether the subject in the present study
trial [2,16,17]. The large twofold increase in the medial and brak- was injured during the stride before making contact with the
ing force loading rates suggest that loading rate may be a more force platform and the observations described were adaptations
sensitive measure of external load compared to peak force mag- to his injury. Full body kinematic data of previous strides were
nitudes. Examination of the center of pressure pattern in relation not available because these strides occurred outside the capture
to the heel marker position did not reveal a clear difference in volume of the cameras originally set for movement occurring on
the point of force application and thus the moment arm of the the force platform. Fortunately, some markers were captured by
resultant force. Assuming a similar moment arm, the higher ex- the cameras which allowed a general view of the whole run. In
ternal loads may have caused increased muscle contraction addition, a video camcorder used for qualitative purposes re-
since muscles activation patterns change in response to varying corded (at 30 Hz) one foot contact before and after the stride on
impact load conditions [10]. It is thought that the increased de- the force platform. In the injury videos provided by Orchard and
mand of muscular work to dissipate energy of the high impact colleagues (www.bjsportmed.com) [18], the cricket player who
shock may possibly cause injury. injured his left gastrocnemius during the push-off phase made
During the initial stance phase, hip flexion, knee flexion and an- whole body adjustments during the following right foot contact
kle dorsiflexion actions all aid in absorbing energy and thus at- and the flight phase. These adjustments were very obvious and
tenuating impact shock, which can be indicated by negative joint happened quickly within 0.2 s before the next touchdown of the
power. The abnormal touchdown body configuration during the injured leg. In the present study, qualitative analysis of the video
injured trial may have hindered the necessary knee flexion and and partial marker set reveals no distinct difference in move-
ankle dorsiflexion. The insufficient knee and ankle contributions ment pattern before the subject made contact with the force
may be compensated by the hip action, as shown by increased platform between the injured and noninjured trials. For the in-
flexion, extension moment and absorption power. The lack of jured trial, obvious adjustments occurred in the stride after the
knee support to absorb impact shock in the injured trial is also subject made contact with the force platform. This confirmed
reflected by the unusual increase in knee flexion moment in- the injury did not happen during the push-off phase of the pre-
stead of extension moment following the touchdown. These ob- vious stride and strengthened the evidence that it occurred
servations suggest that the subject used altered muscle actions while the foot was in contact with the force platform. The differ-
ence in timing of injury occurrence between the present study
and that by Orchard and colleagues [18] is likely due to the dif- 7 Hreljac A. Etiology, prevention, and early intervention of overuse inju-
ries in runners: a biomechanical perspective. Phys Med Rehabil Clin N
ferent touchdown conditions. In their study, the cricket player
Am 2005; 16: 651 – 667
accelerated forward from a stationary posture with close to zero 8 Jacobs R, Bobbert MF, van Ingen Schenau GJ. Mechanical output from
horizontal velocity. In contrast, the subject in the present study individual muscles during explosive leg extensions: the role of biartic-
made contact with the force platform at 4.99 m • s–1 which re- ular muscles. J Biomech 1996; 29: 513 – 523
quired muscular work to attenuate shock during the early im- 9 Kadaba MP, Ramakrishnan HK, Wootten ME. Lower extremity kine-
matics during level walking. J Orthop Res 1990; 8: 849 – 860
pact phase.
10 Komi PV, Gollhofer A, Schmidtbleicher D, Frick U. Interaction between
It is interesting to note that the injured cricket player in the case man and shoe in running: considerations for a more comprehensive
report by Orchard and colleagues [18] felt “100 % certain” the measurement approach. Int J Sports Med 1987; 8: 196 – 202
moment of injury after watching the video showing a sudden ap- 11 Lichtwark GA, Bougoulias K, Wilson AM. Muscle fascicle and series
pearance of a deficit in the medial fibers of the lateral gastrocne- elastic element changes along the length of the human gastrocnemius
during walking and running. J Biomech 2007; 40: 157 – 164
mius muscle. In the present study, the experimental data also
12 Lieber RL, Fridén J. Mechanisms of muscle injury gleaned from animal
support the subject’s description of when the injury happened. models. Am J Phys Med Rehabil 2002; 81 (Suppl. 11): S70 – S79
Both case reports suggest that despite the neural delay in per- 13 Lun V, Meeuwisse WH, Stergiou P, Stefanyshyn D. Relation between run-
ception, human subjects are able to determine the approximate ning injury and static lower limb alignment in recreational runners. Br
J Sports Med 2004; 38: 576 – 580
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14 Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987; 15:
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15 Marti B, Vader JP, Minder CE, Abelin T. On the epidemiology of running
Summary injuries. The 1984 Bern Grand-Prix study. Am J Sports Med 1988; 16:
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16 Munro CF, Miller DI, Fuglevand AJ. Ground reaction forces in running: a
In summary, the gastrocnemius muscle strain injury presented
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in this case report is believed to have occurred during the early 17 Nigg BM, Bahlsen HA, Luethi SM, Stokes S. The influence of running ve-
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Acknowledgements 20 Sun JS, Hang YS, Tsuang YH, Cheng CK, Tsao KY, Hsu SH. Morphological
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The author would like to acknowledge Spira Footwear, Inc. for 21 Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo
providing financial support and shoes for use in this study. My BD. A prospective study of running injuries: the Vancouver sun run “in
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delaria, Efren Herrera and Jason van Haselen) for their help in da- 22 Tsuang YH, Lam SL, Wu LC, Chiang CJ, Chen LT, Chen PY, Sun JS, Wang CC.
Isokinetic eccentric exercise can induce skeletal muscle injury within
ta collection and analysis.
the physiologic excursion of muscle-tendon unit: a rabbit model. J Or-
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