Objectives TheTopFive Running InjuriesSeen ... - Podiatry M · ng M e d i c a l E d u c a t i on Objectives 1)Describethefeaturesofthetop runninginjuries. 2)Presentrecentconceptson

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Stress Fractures and StressReactions of Bone: A ChronicRepetitive Stress Injury

DefinitionThe term stress fracture, while

commonly used and easily under-

stood, does not represent the natureand diversity of this frequently foundoveruse injury. Repetitive stress in-jury (RSI) of bone, or stress reaction,are both better suited to describe thisinjury. The majority of injuries thatare diagnosed as stress fracture do

not demonstrate a fracture line andshould not be termed a fracture. Moresevere stress injuries are similar towhat is termed fatigue fractures inother materials. It should be notedthat bone has been found to fail more

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Objectives1) Describe the features of the top

running injuries.

2) Present recent concepts onmuscle imbalance and the relation-ship of core muscles to clinical enti-ties including PFPS and iliotibialband syndrome.

3) Review the significance oftendinopathy and fasciopathy inclinical practice.

4) Review the concept of enthesisand tendinopathy as they pertain toAchilles tendon injuries.

5) Review current theories of thecause of medial tibial stress syndrome.

6) Present current concepts of stressreactions and stress fractures of boneas repetitive stress injuries of bone.

7) Describe an outline of treat-ment recommendations for Achillestendonitis, plantar fasciitis, iliotibialband syndrome, patellofemoral painsyndrome, medial tibial stress andstress reactions of bone.

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SPORTS PODIATRY

The Top FiveRunning

Injuries Seenin the Office—

Part 2Here’s the current evolution in thought,

literature, and treatmentof these conditions.

BY STEPHEN PRIBUT, DPM

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182 | JUNE/JULY 2013 | PODIATRY MANAGEMENT

frequently in tension than incompression.In runners, the most frequently

injured bones are the tibia,metatarsals, and calcaneus. The avail-able data on the other bones offersvarying data, but virtually all lowerextremity bones may be affected, in-cluding the femur, navicular, fibula,cuboid, and cuneiforms.

Stress fractures were first noted byBriethaupt, a military physician, in1855, who noted swelling and pain inthe feet of Prussian military recruits.36

In 1897, radiographic examination re-vealed the nature of the injury and“march fracture” entered the literatureas reported by Stewchow.37 A numberof studies have followed which detailthis injury in both a military popula-tion and within the athletic popula-tion. Estimates of the occurrence inthe running population is that asmany as 10% or more of injuries maybe stress reactions in bone.38

BackgroundBone is a dynamic structure. As a

biological material, it is subject tochange as a result of environmentalstimuli and in response to geneticpredilection. The initial injury mightbe a biological or biochemical abnor-mality or failure at the cellular or bonemulticellular unit (BMU) level. Boneadapts to many levels of intermittent,repetitive compressive and tensionstrains by an increase in density. Inthe presence of abnormally high and

repetitive forces, the ability to heal bymicrodamage repair is not adequate,and more damage than repair occurs.39

In short, an excessive amount ofstress or repetitive stress is occurringwithout the bone having adequate restto allow for adaptation to the stress.In essence, the stress that createsthese injuries is too much, too soon

for the bone.It is important to

keep in mind other con-tributing factors in the de-velopment of RSI of bone.Besides training errorsand the biomechanicalcauses that we usuallythink of, a variety of sys-temic conditions can con-tribute to this injury.These factors include os-teopenia, osteoporosis,other metabolic bone dis-orders, hormonal abnor-malities, inadequate nu-tritional intake, and colla-gen disorders. In women,amenorrhea or oligomen-orrhea may lead to defi-

cient estrogen and low bone mineraldensity. The female athlete triad in-cludes low bone density by definition,along with disordered eating andamenorrhea.40 Overtraining may leadto decreased testosterone levels inmen resulting in osteopenia. Patientsof either gender who have sufferedmultiple stress fractures should have abone density (DEXA) scan performed.

DiagnosisInitial suspicion of a repetitive

stress injury of bone (RSIB) or stressreaction often leads to the clinical di-agnosis. The patient’s history of in-jury, changing pattern of exercise,physical examination, and imagingstudies lead the practitioner to the di-agnosis. The classical presentation isin an athlete presenting with suddenonset of pain during or after a run.Usually, there has been a discernablechange in training habits. Mileagemay have increased, twice a day runsbegun, speed work initiated, a newpair of running shoes used, or therehas been aging of running shoes along


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Relative rest, Absolute Rest. Activity must be reduced to preventcontinued, repetitive overloading of the injured tissue.

Immobilization vs. Eccentric Stretching—Choose one. Carefullyconsider the other in the event of failure.

Physical Therapy modalities—including electrotherapy, ultrasound

Ice—symptomaticHeel lift to reduce strain deformation and loads at the insertion.Orthotic to reduce torque and rotational strain on the tendon.

Running alterations:Avoid over cushioned shoes, which will increase the eccentriccontraction of the calf muscle.

Avoid uphill running. Avoid incline on treadmill. Avoid overstriding which increases the foot to leg angle in dorsiflexion.

TABLE 6Treatment Suggestionsfor Achilles Tendinopathy

MPFL medial patellofemoral ligament

VMO vastus medialis obliquus

PFPS patellofemoral pain syndrome

ITB iliotibial band

ITBS iliotibial band syndrome

MRI magnetic resonance imaging

RSI repetitive stress injury

MTSS medial tibial stress syndrome

VL vastus lateralis

BMU bone multicellular unit

Abbreviations


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with any other contributing factor.Physical examination will usually re-veal a discrete area of tenderness. Cer-tain bones are not as accessible to pal-pation as others are. The pelvic bones,femur, talus, and midtarsal bones arenotoriously difficult to palpate and ex-amine clinically. So, a high level ofsuspicion must be present to reach thediagnosis particularly in the rearfootand midfoot; and the use of imagingshould be considered.41

On the tibia, as is mentioned else-where in this article, a horizontal lineof tenderness is often the differentiat-ing clinical sign from the vertical ten-derness of medial tibial stress syn-drome. Immobilization in a pneumaticwalker for four to six weeks or moreis often helpful for tibial stress frac-tures, and a variety of other stress in-juries of bone.42 Calcaneal stress frac-tures may be suspected when there istenderness upon lateral compressionof the body, rather than at the medialcalcaneal tuberosity or tenderness thatis only plantar to the calcaneus.

In a group of military recruits, themajority (56%) of calcaneal stress re-actions occurred in the posterior thirdof the bone and 79% occurred in theupper half of the calcaneus.43 Earlierreviews noted that the injury oc-curred primarily in the posterior as-pect of the calcaneus, but Sormaalanotes the importance of suspecting a

stress reaction in the more anteriorportion of the bone. Stress fracturesof the tarsal navicular should be sus-pected when there is dorsal tender-ness extending proximally to distally.In addition to simple tenderness, ten-derness to percussion or to the vibra-tions of a tuning fork have been usedas pathognomonic signs.

Diagnostic imaging includes ra-diographic evaluation, technetium-99bone scan, and MRI. Often, an injury

is not visible on radiographic exami-nation. Bone scintigraphy is consid-ered sensitive, while MRI is consid-ered to be both sensitive and specif-ic.41 At early stages, the MRI showsmarrow edema as an increased STIRsignal and in fat-suppressed T2 im-ages. On T1 sequences, a decreasedsignal is noted.44 As the injury pro-gresses to a stage of increasing severi-ty, a low signal fracture line and bonecallus may be visible.

A number of conditions may ap-pear similar to stress fracture on cer-tain imaging studies (Table 7). In other

cases, asymptomatic bone mar-row edema may be visible on MRI.41

TreatmentConservative treatment works

well for most RSI of bone. The key isfinding the appropriate mechanicaltreatment to eliminate the pain ofweight bearing. With the eliminationof pain, the forces should be suffi-ciently low for healing and remodel-ing to take place. Weight-bearing ex-

ercise should be avoided. Multiple au-thors have recommended the use of apneumatic walker for tibial stressfractures.42,45 This may be used aloneor with crutches, as needed. A camwalker, pneumatic walker or lowpneumatic walker may alleviate painfaster and is often clinically superiorto a post-operative shoe for stress re-actions of the metatarsal area, and forother foot stress reactions.

During recovery, one should guidethe athlete to appropriate cross-train-ing activity. Swimming, bicycling, andmaintenance of upper body strengthshould be implemented. Lower ex-tremity exercises should be chosen asappropriate, and if deemed to not riskdelayed healing or further injury.

A phased return to activity, allow-ing sufficient time for healing, is thekey to a successful return to activity.In clinical practice, the author hasfound that weaning from the pneu-matic walker seems to lessen the timeto comfortable exit from the walkerand prevent pain from returning andthe necessity of returning to the useof the pneumatic walker. Most lower-extremity stress reactions take be-tween 8 and 17 weeks for recovery.38

Medial Tibial Stress Syndrome(Shin Splints)

Shin splints, the term that justwon’t die, is still on the frequent in-jury list, but now under a different

Conservative treatment works well for most RSIof bone. The key is finding the appropriate mechanicaltreatment to eliminate the pain of weight bearing.


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Conditions that may appear to be a stress fracture

Patellofemoral pain syndromeOsteoid osteomaOsteomyelitisOsteosarcomaEwing TumorBone metastasesOsteochondral fractureAccessory Navicular (painful)Inflammatory disordersMedial Tibial Stress Syndrome

TABLE 7Differential Diagnosis of LowerExtremity Stress Fracture

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name.. The terms anterior shinsplints, posteromedial shin splints,

and a host of other terms came intovogue in the 1970’s and 1980’s. Aslong ago as 1967, Slocum encouragedthe abandonment of the term shinsplints from the medical literature.46

Ten years later, James also supportedthe efforts to eliminate the term sug-gesting posterior tibial syndrome asan alternative.47

The improved descriptive termmedial tibial stress syndrome is nowin common use. The term was firstapplied by R. Drez and popularizedby Mubarak in 1982.48 This term is ap-propriate to use in the absence of astress fracture or an exertional com-partment syndrome. The older term,shin splints, never made clear whatpart of the leg was affected. Somehave considered the shin to be thefront part of the leg below the knee,the front part of the tibia, or the lowerleg itself. We will omit considerationof anterior tibial leg pain and reviewthe medial portion of the tibia that theterm medial tibial stress syndrome(MTSS) refers to.

Historically included entities with-in the realm of MTSS include: perios-titis, traction periostalgia, tendinopa-thy, periosteal reaction, and fatiguefailure of the connective tissue con-necting muscle to bone.49

Where is the Pain? Symptoms andDescription

By definition, the pain in MTSSoccurs at the posteriomedial aspect ofthe tibia. Edwards has detailed an al-gorithmic approach to diagnosis andconfirmatory tests to differentiateMTSS from nerve injury and compart-ment syndrome.50 He suggests thatMTSS may occur more often in thedistal third of the tibia, and oneshould consider stress fracture moreproximally. While his flow chart is in-teresting, it is severely flawed. MTSSis considered as a strong possibilitywith pain at rest in the presence ofpalpable tenderness. In the absence ofpain at rest, but with palpable tender-ness, he considers common or super-ficial nerve entrapment as the likelycause of lower limb pain.

Unfortunately, in the context oftreating runners, this makes little

sense. He notes elsewhere in his arti-cle that the pain in the early stagesdoes fade with rest. Previous observa-tions of overuse injuries and pain-staging better and more accurately de-fine the pain seen with thiscondition.51-53 See Table 8 for a stagingof pain occurring in overuse injuries.Nerve compression or entrapmentsyndromes are usually consideredwhen the history includes the descrip-tion of pain that is burning in natureand may be associated with a subjec-tive or objective observation of numb-ness. Exertional compartment syn-dromes, which present with a some-what different set of symptoms, willnot be reviewed within this paper.

Michael and Holder54 describedthe clinical characteristics of earlyMTSS as including:

1) Induced by exercise, relievedby rest;

2) Dull ache to intense pain;3) Tenderness posterior medial

border of tibia;4) Pronated feet;5) Normal x-ray films.

Risk FactorsThacker49 reviewed the available

epidemiological literature and found ageneral consensus that there were avariety of potential risk factors de-tailed in the literature. The risk fac-tors most often cited include: youngerage, female gender, change in dis-tance, frequency, speed, surface ofruns, change of running shoes, excesspronation, and a previous history ofinjury. As is often the case in themedical literature, contrary studiesare often found. Contrary studies arealso cited on age, gender, mileage,hill running, running surface, previ-ous activity level and flexibility. Inour constant quest for high level stud-ies that are reliable and meet the re-quirements of evidence-based


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Stage 0—No pain is present before, during or after activity. Minordiscomfort may be experienced at various times during training orracing.

Stage 1—Pain or stiffness after activity. The pain is usually gone bythe next day.

Stage 2—Mild discomfort before activity that goes away soon afterexercise is commenced. No pain is present in the latter part of theexercise. Pain returns after the exercise is completed (starting within1 to 12 hours later and lasts up to 24 hours).

Stage 3—Moderate pain is present before sport. Pain is present dur-ing sport activity, but is somewhat decreased. The pain is an annoy-ance which may alter the manner in which the sport is performed.

Stage 4—Significant pain before, during, and after activity. The painmay disappear after several weeks of rest.

Stage 5—Pain before, during, and after activity. The athlete hasstopped their sports participation because of the severity of the pain.The pain does not abate completely even after weeks of inactivity.

TABLE 8

Pribut Pain Staging ofOveruse Injuries in Athletes


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medicine, we often find ourselveswandering in the mire of the litera-ture and decide that the evidence isthin for much of what we think weknow. We remain with the knowl-edge of the importance of having abasic understanding of causative fac-tors in the context of carefully assess-ing an individual patient.

ImagingWhile clinical signs and symp-

toms will lead you to the diagnosis inmany cases, it still may be helpful torule out a stress fracture. Radiographsshould be taken in questionablecases, but they are often insufficientlysensitive to show many stress frac-tures and offer no information thatwould demonstrate MTSS.

Both triphasic bone scans (dif-fuse, superficial, linear uptake) andMRI (diffuse linear signal on T2) havebeen used to demonstrate stress frac-ture and, in many cases, they maydemonstrate linear patterns suggest-ing MTSS; although negative studiesdo not preclude the diagnosis ofMTSS.

MTSS—CausesThere are a variety of theories of

the pathogenesis of MTSS. Periostitiswas one widely believed to be thecause of the pain, but histologicallyinflammation was not found.55 Pe-riostalgia has been applied to pain atthis site in the absence of inflamma-tion. Johnell, et al., found metabolicchanges in bone with no inflamma-tion and believed MTSS to be a stressreaction of bone. Other theorists haveproposed traction injury at the poste-rior tibialis and/or soleus muscles.54

Bates in 1985 postulated that ex-cessive pronation and eccentric con-traction of the soleus and posteriortibial muscles were contributing fac-tors in the development of MTSS.56

Factors that increase bending mo-ments or traction at these sites in-clude a planus foot type, tarsal coali-tion, leg length inequality, and mus-cle imbalance.57

The tibialis posterior muscle ori-gin has been noted to be in the uppertwo thirds of the interosseus mem-brane, medial fibula, and lateral tibia.It is somewhat proximal to where the

bulk of the tenderness is usuallynoted clinically. Beck and Osternigperformed cadaver dissections whichdemonstrated that the soleus, flexordigitorum longus and deep crural fas-cia were close to the usual areas inwhich symptoms were found and theposterior tibialis muscle was found aconsiderable distance proximally.58 Inspite of the downplaying of the tib-ialis posterior by its anatomical posi-tion, under eccentric contraction,Pribut postulates that it should stillsubstantially increase the strain in themedial tibia.

Bouché and Johnson researchedtraction resulting upon the tibial fas-cia when forces are applied to theposterior tibial, soleus, and flexor dig-itorum longus tendons.59 In their dis-cussion, they noted that these mus-

cles eccentrically contract duringstance to counter midtarsal and subta-lar joint pronatory forces, which earli-er had been linked to MTSS.60 Bouchéand Johnson’s study demonstrated adirect linear relationship betweenforces applied to those muscles andstrain measured at the muscle boneinterface, and the conclusion theyreached was that “eccentric contrac-tion of the superficial and deep flexortendons of the leg is the key pathome-chanical factor …” in the creation ofMTSS.59 Bouché also noted that exer-cising on hard floors had been foundto increase eccentric contractions ofthese muscles. The research ofBouché sits well with the conceptsearlier espoused by Michael, et al. intheir article entitled “The Soleus Syn-drome.”54 Michael’s suggestion thatthe soleus could contribute to “shinsplints” was based on cadaver, EMG,and muscle stimulation research.

Treatment and PreventionThus far, a number of studies

have surprisingly failed to show pre-vention from graded increase in exer-

cise programs. There are a num-ber of possible experimental de-sign measures that might show differ-ences better, but at this point the evi-dence that would back up commonsense is not there. Thacker notes seri-ous “methodological flaws” in thestudies he reviewed.49

It is important to include rest andrelative rest at the top of recommen-dations. Two to four weeks of restmay alleviate much of the pain inearly MTSS. Training alterationsprior to the development of MTSSneed to be carefully analyzed andrecommendations should be madebased upon this analysis. A biome-chanical analysis of the lower ex-tremity should be performed, andshoe and custom orthotic recommen-dations are made as needed.50 Exces-

sive pronation has been found to bea contributing factor.

NSAIDS, while not directly ad-dressing inflammation, are useful ad-juncts to pain control and allow theearly resumption of normal motionpatterns and strengthening andstretching exercises. Gastrosoleusstretching should be undertaken. Coremuscle strengthening is becoming in-creasingly used for a variety of lowerextremity overuse injuries and shouldbe evaluated for strength deficit.

During the rest period, the athletewill need to be given a program of al-ternative exercise. This may consist oflow impact cardiovascular exercisessuch as swimming, stationary bicycle,or pool running. It may be supple-mented with upper body weight train-ing. Gradual return to activity and in-crementally building up distance andintensity should assist in a smooth re-turn to normal activity.

Plantar Fasciopathy, Plantar HeelPain Syndrome

Plantar fasciitis is one of the most

It is important to include rest and relative restat the top of recommendations. Two to four weeks of rest

may alleviate much of the pain in early MTSS.


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frequently found foot injuriesamong runners. As with several

other entities, we are discovering thatmany of the terms we have calledthis by are likely incorrect. The heelpain we most often see has beencalled many things including plantarheel pain, heel spur syndrome, andrecently plantar heel pain syn-drome.61 In the term fasciitis, the -itisending denotes an inflammation. Per-haps if we redefined -itis, we couldstill use fasciitis and tendonitis, butthe death of the term plantar fasciitisis rapidly approaching.

Lemont examined specimens and

found no inflammation present. In-stead, he found changes analogous tothat found in tendinosis: myxoid de-generation, collagen degeneration, in-creased vascularization, and vascularengorgement of the adjacent bonemarrow.62 Evidence of inflammationwas not seen. While Lemont indicat-ed that plantar fasciitis should be con-sidered plantar fasciosis, this latterterm is probably best termed fasciosisafter biopsy, and plantar fasciopathyis a more suitable term.

The term plantar heel pain syn-drome can be used to include condi-tions of pain in this region in both the

absence and presence of an inferiorcalcaneal spur.

The origin of the plantar fascia isan enthesis similar to the Achillestendon. Fibrocartilage is found at itssite of origin. Growing heel spurs ap-pear to take shape deep to the plan-tar fascia and have been noted togrow within developing cartilage viaendochondral and intramembranousossification, most likely at the site ofthe enthesis and in close associationwith the flexor digitorum brevis.63

Recent thinking is that this is not atraction injury but an enthesophyteformed in the enthesis via stimula-tion of the bone by stress. Pribut hashypothesized that even in the ab-sence of direct traction injury at thesite of origin of the plantar fascia,there will be sufficient strain in theenthesis and in the calcaneus tostimulate bone and cartilage produc-tion and sufficient strain to also cre-ate other calcaneal stress injuries.Early changes occurring in the enthe-sis fibrocartilage near the calcanealsurface include the appearance ofcartilage cell clusters and longitudi-nal fissure formation with erosion ofsubchondral bone.

Most spurs develop deep to theplantar fascia in the flexor digitorumbrevis, quadratus plantae and abduc-tor hallucis muscle origins.63a It is logi-cal to conclude that the muscles origi-nating in this area, especially thequadratus plantae, may play a signifi-cant role in the plantar heel pain syn-drome. The other intrinsic musclesare also likely to be involved in thissyndrome. Unfortunately, this is notoften discussed or considered in arti-cles and lectures on “plantar fasciopa-thy.” Discussion and debate is oftenlimited to “the spur is not in the fas-cia”, “vertical forces might be in-volved rather than traction” and“does the spur cause the pain”? Thereal questions are “what is the totalityof structures contributing to thepain?”, “what role do the intrinsicmuscles play both in the developmentof pain and production of the heelspur?” , “what does it mean thatmuch of the anatomy in this area is apart of an enthesis?”, and “whatshould we do to eliminate the pain,


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MechanicalPlantar FasciopathyPlantar enthesopathyMuscle strain at origin of quadratus plantae, abductor hallucis,

or flexor hallucis brevis

Repetitive TraumaStress fracturesRupture of plantar fasciaHeel pad atrophy

NeurologicalPosterior tibial nerve—tarsal tunnel syndromeMedial calcaneal nerveMedial plantar nerveLateral plantar nervePeripheral neuropathyDiscogenic painCentral nervous system lesion

ArthriticSeronegative SpondyloarthropathiesRheumatoid ArthritisFibromyalgiaGoutEnthesopathy

Misc.InfectionBone cyst or tumorApophysitis

TABLE 9

Selected Entities CausingPlantar Heel Pain


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improve function, and keep our run-ners on the road?”

SymptomsPain upon arising in the morn-

ing is one of the hallmarks of plan-tar heel pain syndrome. The pain isnoted to be on the plantar or plantarmedial aspect of the heel. Tender-ness is usually found upon palpa-tion of the medial calcaneal tuberos-ity. It is important to distinguishplantar fasciitis from a tear of theplantar fascia, which most often oc-

curs 2-6 cm anterior to the origin ofthe plantar fascia and from a cal-caneal stress fracture. The tender-ness of most calcaneal stress frac-tures is linear and found on thebody of the calcaneus, often on boththe medial and lateral sides. Nerveentrapment may also cause pain inthis region. Table 9 details some ofthe clinical entities that can causeplantar heel pain.

TreatmentEntire issues and seminars are de-

voted to plantar heel pain and itstreatment. We will briefly review cur-rent therapy. A survey of members ofthe American Academy of PodiatricMedicine detailed the most commontreatments that they employ for plan-tar heel pain syndrome.61 Recommen-dations based on this survey and sub-sequent observations follow.

For early heel pain of less than sixweeks duration, the most frequentrecommendations were for avoidance

of walking barefoot or walking in flatshoes, over the counter inserts, regu-lar calf stretching, cryotherapy, non-steroidal, anti-inflammatory drugs(NSAIDs), and strapping of the foot.Toe crunches or marble pickups de-signed to improve the strength of theintrinsic muscles should be started.

At an intermediate stage, whenpain has been present for six weeks tosix months, the respondents usually

recommended a custom orthot-ic. Corticosteroid injections werealso frequently recommended—al-though, in view of Lemont’s findings,the rationale of such injections needsto be reconsidered.62 The increasedrisk of rupture of the plantar fasciafollowing both corticosteroid injectionand exercising after these injectionsshould also be taken into considera-tion. Night splints were also some-times used.

Additional measures recommend-ed for late stage plantar fasciopathyinclude immobilization via the use ofa cast or pneumatic walker, plantarfasciotomy, and extracorporeal shock-wave therapy.

Plantar fascia rupture is not a com-monly found running injury. Whenthis occurs it is readily treated withpneumatic cast boot immobilizationusing pain as a guide as to whenweight bearing should be permitted.Generally 6–8 weeks of immobilizationfollowed with an orthotic and rehabili-tative exercises works well. Thismethod has been used in our officesfor over 25 years. A similar methodwas detailed in 2004 by Saxena andFullem with a study of over 18 cases.62a

It is important to examine yourpatient’s running shoe to make cer-tain that flexion and torsional stabilityis present. If the shoe is excessivelyflexible, more forces will be createdwithin and near the plantar fascia,most likely via the windlass effect. Ifthe pain has been severe enough tocause the patient to miss severalweeks’ worth of running, a slow andgradual return is important to avoidrecurrence of injury or a new overuseinjury. Intrinsic muscle strengtheningand calf muscle stretching need to beperformed by the athlete regularly.An outline of treatment recommenda-tions follows in Table 10.

An Unusual Presentationof Heel Pain

Sometimes the very rare and dan-gerous can masquerade as the ordi-nary and simple. A middle aged run-ner presented to my office with acomplaint of burning pain in his heelwhich occurred at random times. Nolocal tenderness was found. No


Relative or Absolute RestCalf StretchingIntrinsic muscle strengthening (towel toe crunches, marble pick-ups, etc.)CryotherapyNSAIDs (for pain, not inflammation)Night splintsOTC InsertCustom Foot orthosesShoes—with increased torsional & flexion stabilityCheck Stability of running and walking shoes, replace if necessaryAvoid barefoot walkingAvoid calf raises and stair dips and other forefoot-only contact exercises

TABLE 10

Outline of TreatmentRecommendations for Plantar

Heel Pain Syndrome

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It is important to examine your patient’srunning shoe to make certain that flexion and

torsional stability is present.

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Tinel’s sign was found nor wasreferred pain found in examination

of the tarsal tunnel area. The burningwas taken to be evidence of a neuro-logical problem, possibly at the levelof the spinal nerves (although tarsaltunnel syndrome was a lesser consid-eration). The patient was referred to aneurologist for evaluation. The neu-rologist felt the ocular examination tobe most significant. Upon ocular ex-amination, increased intracranialpressure was suspected. A brain scanrevealed a lesion in the cerebral cor-tex (near the sensory region). The le-sion was a well-differentiated glioma.Within the first month followingsurgery, the symptoms were no bet-ter. As recovery proceeded followingthe surgery, within 3 months the heelpain symptoms abated and have notreturned after 5 years. It is unlikelyyou’ll ever see a case like this. Butyou are likely to see something rare inyour practice. Keep your eyes openand your mind ready.

SummaryThe study and quest for under-

standing athletic injuries is a lifelongundertaking. We have tried to give apicture of some of the most commonrunning injuries in this article and todetail the evolution of thought thathas occurred over the last fewdecades on these commonly seenclinical entities. We hope your inter-est has been piqued to continue learn-ing about these maladies and that youdevelop a method of assessing the lit-erature to better treat your patients.To enhance your knowledge of sportsmedicine in a face-to-face setting, Iencourage you to attend lectures onthese topics. Venues which includeinformation of interest to the podiatricsports medicine physician include theAnnual APMA Scientific Seminar fea-turing a track put on by the AAPSM,regional meetings which feature theAAPSM and a variety of lecture seriesat the podiatric medical collegeswhich are jointly put on with theAAPSM. Information on these meet-ings can be found at the website ofthe AAPSM (www.aapsm.org). PM

References36 Breithaupt, J., Zur pathologie des

menschlichen fussess. 1855; 24:169-177.Medizin Zeitung, 1855. 24: p. 169-177.

37 Stechow, Fussödem und Röntgen-strahlen. Deutsche MilitärärztlicheZeitschrift, 1897. 26: p. 465.

38 Matheson, G.O., et al., Stress frac-tures in athletes. A study of 320 cases. Am JSports Med, 1987. 15(1): p. 46-58.

39 Akkus, O. and C.M. Rimnac, Corticalbone tissue resists fatigue fracture by decel-eration and arrest of microcrack growth. JBiomech, 2001. 34: p. 757-764.

40 Lebrun, M., The Female AthleteTriad: What’s a Doctor to Do? CurrentSports Medicine Reports, 2007. 6: p. 397-404.

41 Niva, M.H., et al., Bone stress injuriesof the ankle and foot: an 86-month magneticresonance imaging-based study of physicallyactive young adults. Am J Sports Med, 2007.35(4): p. 643-9.

42 Swenson, E.J., et al., The Effect of aPneumatic Leg Brace on Return to Play inAthletes with Tibial Stress Fractures. Am. J.Sports Med., 1997. 25(June): p. 322-328.

43 Sormaala, M.J., et al., Stress Injuriesof the Calcaneus Detected with MagneticResonance Imaging in Military Recruits. JBone Joint Surg Am, 2006. 88: p. 2237-2242.

44 Stafford, S.A., D.I. Rosenthal, andM.C. Gebhardt, MRI in Stress Fracture. AJRAm J Roentgenol, 1986. 147: p. 553-556.

45 Fredericson, M., et al., Tibial stressreaction in runners. Correlation of clinicalsymptoms and scintigraphy with a newmagnetic resonance imaging grading sys-tem. Am J Sports Med, 1995. 23(4): p. 472-81.

46 Slocum, D.B., The shin splint syn-drome. Am J Surg, 1967. 114: p. 875-881.

47 James, S.L., B.T. Bates, and L.R. Os-ternig, Injuries to Runners. Am J SportsMed, 1978. 6: p. 40-50.

48 Mubarak, S.J., et al., The Medial Tib-ial Stress Syndrome: A Cause of ShinSplints. Am J Sports Med, 1982. 10(4): p.201-205.

49 Thacker, S.B., et al., The preventionof shin splints in sports: a systematic reviewof literature. Med Sci Sports Exerc, 2002.34(1): p. 32-40.

50 Edwards, P.H., M.L. Wright, and J.F.Hartman, A Practical Approach for the Dif-ferential Diagnosis of Chronic Leg Pain inthe Athlete. Am J Sports Med, 2005. 33: p.1241-1249.

51 MacIntyre, J.G., J.E. Taunton, andD.B. Clement, Running injuries: a clinicalstudy of 4,173 cases. Clin J Sport Med,1991. 1(2): p. 81-87.

52 O’Connor, F.G., T.M. Howard, andC.M. Fieseler, Managing Overuse Injuries: ASystematic Approach. Physician &Sportsmedicine, 1997. 25(5): p. 11.

53 Pribut, S.M., A Quick Look At Run-

ning Injuries. Podiatry Management, 2004.23(1): p. 57-68.

54 Michael, R.H. and L.E. Holder, TheSoleus Syndrome. Am J Sports Med, 1985.13(2): p. 87-94.

55 Detmer, D.E., Chronic shin splints.Classification and management of medialtibial stress syndrome. Sports Med, 1986.3(6): p. 436-46.

56 Bates, P., Shin splints—a literature re-view. Br J Sports Med, 1985. 19(3): p. 132-7.

57 Sommer, H.M. and S.W. Vallentyne,Effect of foot posture on the incidence ofmedial tibial stress syndrome. Med SciSports Exerc, 1995. 27(6): p. 800-804.

58 Beck, B.R. and L.R. Osternig, Medialtibial stress syndrome. The location of mus-cles in the leg in relation to symptoms. JBone Joint Surg Am, 1994. 76(7): p. 1057-1061.

59 Bouche, R.T. and C.H. Johnson, Me-dial Tibial Stress Syndrome (Tibial Fasci-itis): A Proposed Pathomechanical ModelInvolving Fascial Traction. J Am PodiatrMed Assoc, 2007. 97(1): p. 31-36.

60 Viitasalo, J.T. and M. Kvist, Somebiomechanical aspects of the foot and anklein athletes with and without shin splints.Am J Sports Med, 1983. 11(3): p. 125-30.

61 Pribut, S.M., Current Approaches tothe Management of Plantar Heel Pain Syn-drome, Including the Role of Injectable Cor-ticosteroids J Am Podiatr Med Assoc, 2007.97(1): p. 68-74.

62 Lemont, H., K. Ammirati, and N.Usen, Plantar Fasciitis A Degenerative Pro-cess (Fasciosis) Without Inflammation. JAm Podiatr Med Assoc, 2003. 93(3): p. 234-237.

62a Saxena A, Fullem B., Plantar fasciaruptures in athletes. Am J Sports Med. 2004Apr-May;32(3):662-5.

63 Kumai, T. and M. Benjamin, Heelspur formation and the subcalcaneal enthe-sis of the plantar fascia. J Rheumatol, 2002.29(9): p. 1957-64.

63a Smith S, Tinley P, Gilheany M, GrillsB, Kingsford A. The inferior calcanealspur—anatomical and histological consider-ations. Foot. 2007;17:25-31. doi:10.1016/j.foot.2006.10.002.

Dr. Pribut is a ClinicalAssistant Professor ofSurgery at GeorgeWashington UniversityMedical School. Heserves on the Runner’sWorld Board of Advi-sors. He is a past presi-dent of the AmericanAcademy of Podiatric

Sports Medicine. Dr. Pribut is in private practicein Washington, DC.

Continuing

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CME EXAMINATION

1) Stress fractures occurring inthe lower extremity in runnersare best demonstrated using:

A) a bone scanB) computed tomographyC) x-rayD) tuning fork

2) Diffuse activity along the poste-riomedial aspect of the tibia visi-ble on bone scintigraphy probablyindicates:

A) osteogenic sarcomaB) stress fractureC) medial tibial stresssyndromeD) osteomyelitis

3) In reference to the impact onthe patellofemoral complex, thevastus medialis oblique is:

A) a static stabilizerB) a dynamic stabilizerC) a passive stabilizerD) a destabilizer

4) The patella has the leastamount of medial stability at:

A) zero degrees of flexionB) 20 degrees of flexionC) 45 degrees of flexionD) 90 degrees of flexion.

5) Factors considered important tothe development of patellofemoralpain syndrome include:

A) abnormal pronation of thefootB) patella altaC) weak hip abductor musclesD) all of the above.

6) Pain that develops after run-ning in the anterior region of a pa-tient’s knee is most likely to bewhat is appropriately termed:

A) Runner’s KneeB) Patellofemoral pain syndromeC) chondromalacia patellaeD) terrible triad

7) Evidence in studies hasindicated that a large contribut-ing factor to iliotibial bandsyndrome is:

A) weak hip abductormusclesB) over pronation of the footC) high archesD) low blood levels ofVitamin D

8) The pain of iliotibial band syn-drome is most often experiencedin the region of the:

A) anterior kneeB) posterior aspect of thekneeC) medial aspect of the kneeD) lateral aspect of the knee.

9) The most frequently occurringAchilles tendon injuries in run-ners are best termed

A) Achilles tendonitisB) Achilles heelC) Achilles bursitisD) Achilles tendinopathy

10) All of the following typesof footgear could aggravate painin the Achilles tendon areaexcept:

A) zero drop, minimalist shoesand a switch to forefoot con-tact running styleB) firm heel shoe, flexible atball, with 1/4” heel liftC) well-cushioned shoesD) shoes with a stiff and hard-to-bend sole.

11) The insertion of the Achillestendon and the plantar fascia aresimilar in that they both:

A) insert into the talusB) are both improved with stiffrunning shoesC) are improved by jumpingjacks and running in sandD) are entheses

12) The histological findings oftendinosis include:

A) myxoid degenerationB) parakeratosisC) inflammatory exudatesD) copius lymphocytes

13) Stress fractures of the tibiado not usually demonstrate:

A) horizontal line oftendernessB) diffuse linear verticaluptake on scintigraphyC) negative findings onx-rayD) focal area of concentrateduptake in proximal 1/3 oftibia on scintigraphy

14) In the detection of stressfractures of the lower extremity,the following imaging studyis considered sensitive andspecific:

A) Te-99 Bone ScinigraphyB) MRIC) UltrasoundD) X-ray

15) Pain and tenderness at theposteriomedial aspect of thetibia in runners:

A) is best treated with corti-costeroid injectionsB) is most often a stressfractureC) is caused by a tight or aweak anterior tibialismuscleD) often falls into the catego-ry of posterior tibial stresssyndrome

16) The following statementabout patellofemoral pain disor-der is false:

A) the preferred name of thiscondition is anterior kneepain


SEE ANSWER SHEET ON PAGE 191.


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B) pronation of the foot has been found instudies to be a risk factorC) studies indicate weak hip abductors to beassociated with PFPSD) the subchondral bone, extensor retinacu-lum and infrapatellar fat pad are possiblesources of pain in PFPS.

17) All of the following statements about theAchilles tendon insertion are true except:

A) Fibrocartilage is found at the insertion ofthe Achilles tendonB) Sesamoidal cartilage is found at the inser-tion of the Achilles tendonC) periosteal cartilage is found at the inser-tion of the Achilles tendonD) articular cartilage is found at the insertionof the Achilles tendon

18) Surgical treatment of Achilles tendinosismost commonly would likely include any of thefollowing except:

A) stripping of the paratenonB) excision of non-viable tissueC) Gastrocnemius recession (e.g., StrayerProcedure)D) linear tenotomy

19) The tibialis posterior muscle originatesfrom the:

A) distal medial aspect of the tibiaB) the proximal interosseus membrane,medial fibula and lateral tibiaC) proximal 2/3 of the tibia onlyD) distal fibula and tibia

20) Although evidence based proof is weak,overuse running injuries are thought to be con-tributed to by all of the following except:

A) carbohydrate loadingB) overtrainingC) shoes losing shock absorption and wearingdown substantiallyD) starting marathon training never havingrun more than 20 minutes at a time

See answer sheet on page 191.

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Strongly Stronglyagree Agree Neutral Disagree disagree[5] [4] [3] [2] [1]

1) This CME lesson was helpful to my practice ____

2) The educational objectives were accomplished ____

3) I will apply the knowledge I learned from this lesson ____

4) I will makes changes in my practice behavior based on thislesson ____

5) This lesson presented quality information with adequatecurrent references ____

How long did it take you to complete this lesson?

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What topics would you like to see in future CME lessons ?

Please list :

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

__________________________________________________

1. A B C D

2. A B C D

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

16. A B C D

17. A B C D

18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #5/13The Top Five Running Injuries Seen

in the Office—Part 2 (Pribut)

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Documents

Objectives TheTopFive Running InjuriesSeen ... - Podiatry M · ng M e d i c a l E d u c a t i on Objectives 1)Describethefeaturesofthetop runninginjuries. 2)Presentrecentconceptson