M C e o di n ca ti l nu SPORTS PODIATRY E in du g ca ti on

Objectives 1) Describe the features of the top The Top Five injuries. 2) Present recent concepts on muscle imbalance and the relation - Running ship of core muscles to clinical enti - ties including PFPS and . Injuries Seen 3) Review the significance of and fasciopathy in clinical practice. in the Office— 4) Review the concept of enthesis and tendinopathy as they pertain to injuries. Part 2 5) Review current theories of the cause of medial tibial stress syndrome. 6) Present current concepts of stress Here’s the current evolution in thought, reactions and stress fractures of bone literature, and treatment as repetitive stress injuries of bone. of these conditions. 7) Describe an outline of treat - ment recommendations for Achilles tendonitis, plantar , iliotibial band syndrome, patellofemoral pain BY STEPHEN PRIBUT, DPM syndrome, medial tibial stress and stress reactions of bone.

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Stress Fractures and Stress stood, does not represent the nature not demonstrate a fracture line and Reactions of Bone: A Chronic and diversity of this frequently found should not be termed a fracture. More Repetitive Stress Injury overuse injury. Repetitive stress in - severe stress injuries are similar to jury (RSI) of bone, or stress reaction, what is termed fatigue fractures in Definition are both better suited to describe this other materials. It should be noted The term stress fracture, while injury. The majority of injuries that that bone has been found to fail more commonly used and easily under - are diagnosed as stress fracture do Continued on page 182 www.podiatrym.com JUNE/JULY 2013 | PODIATRY MANAGEMENT | 181 n ng io SPORTS PODIATRY ui at in c t du on E C al ic ed M frequently in tension than in compression. In runners, the most frequently TABLE 6 injured bones are the , metatarsals, and calcaneus. The avail - Treatment Suggestions able data on the other bones offers for Achilles Tendinopathy varying data, but virtually all lower extremity bones may be affected, in - cluding the , navicular, fibula, Relative rest, Absolute Rest. Activity must be reduced to prevent cuboid, and cuneiforms. continued, repetitive overloading of the injured tissue. Stress fractures were first noted by Briethaupt, a military physician, in Immobilization vs. Eccentric Stretching—Choose one. Carefully 1855, who noted swelling and pain in consider the other in the event of failure. the feet of Prussian military recruits. 36 In 1897, radiographic examination re - Physical Therapy modalities—including electrotherapy, ultrasound vealed the nature of the injury and “march fracture” entered the literature as reported by Stewchow. 37 A number Ice—symptomatic of studies have followed which detail lift to reduce strain deformation and loads at the insertion. this injury in both a military popula - Orthotic to reduce torque and rotational strain on the tendon. tion and within the athletic popula - tion. Estimates of the occurrence in Running alterations: the running population is that as Avoid over cushioned shoes, which will increase the eccentric many as 10% or more of injuries may contraction of the calf muscle. be stress reactions in bone. 38 Avoid uphill running. Avoid incline on treadmill. Avoid over Background striding which increases the foot to leg angle in dorsiflexion. Bone is a dynamic structure. As a biological material, it is subject to change as a result of environmental stimuli and in response to genetic repetitive forces, the ability to heal by cient estrogen and low bone mineral predilection. The initial injury might microdamage repair is not adequate, density. The female athlete triad in - be a biological or biochemical abnor - and more damage than repair occurs. 39 cludes low bone density by definition, mality or failure at the cellular or bone In short, an excessive amount of along with disordered eating and multicellular unit (BMU) level. Bone stress or repetitive stress is occurring amenorrhea. 40 Overtraining may lead adapts to many levels of intermittent, without the bone having adequate rest to decreased testosterone levels in repetitive compressive and tension to allow for adaptation to the stress. men resulting in osteopenia. Patients strains by an increase in density. In In essence, the stress that creates of either gender who have suffered the presence of abnormally high and these injuries is too much, too soon multiple stress fractures should have a for the bone. bone density (DEXA) scan performed. It is important to keep in mind other con - Diagnosis Abbreviations tributing factors in the de - Initial suspicion of a repetitive velopment of RSI of bone. stress injury of bone (RSIB) or stress MPFL medial patellofemoral ligament Besides training errors reaction often leads to the clinical di - VMO vastus medialis obliquus and the biomechanical agnosis. The patient’s history of in - causes that we usually jury, changing pattern of exercise, PFPS patellofemoral pain syndrome think of, a variety of sys - physical examination, and imaging ITB iliotibial band temic conditions can con - studies lead the practitioner to the di - ITBS iliotibial band syndrome tribute to this injury. agnosis. The classical presentation is These factors include os - in an athlete presenting with sudden MRI magnetic resonance imaging teopenia, osteoporosis, onset of pain during or after a run. RSI repetitive stress injury other metabolic bone dis - Usually, there has been a discernable orders, hormonal abnor - change in training habits. Mileage MTSS medial tibial stress syndrome malities, inadequate nu - may have increased, twice a day runs VL vastus lateralis tritional intake, and colla - begun, speed work initiated, a new BMU bone multicellular unit gen disorders. In women, pair of running shoes used, or there amenorrhea or oligomen - has been aging of running shoes along orrhea may lead to defi - Continued on page 183

182 | JUNE/JULY 2013 | PODIATRY MANAGEMENT www.podiatrym.com M C SPORTS PODIATRY e o di n ca ti l nu RUNNING INJURIES E in du g ca ti on with any other contributing factor. stress reaction in the more anterior cases, asymptomatic bone mar - Physical examination will usually re - portion of the bone. Stress fractures row edema may be visible on MRI. 41 veal a discrete area of tenderness. Cer - of the tarsal navicular should be sus - tain bones are not as accessible to pal - pected when there is dorsal tender - Treatment pation as others are. The pelvic bones, ness extending proximally to distally. Conservative treatment works femur, talus, and midtarsal bones are In addition to simple tenderness, ten - well for most RSI of bone. The key is notoriously difficult to palpate and ex - derness to percussion or to the vibra - finding the appropriate mechanical amine clinically. So, a high level of tions of a tuning fork have been used treatment to eliminate the pain of suspicion must be present to reach the as pathognomonic signs. weight bearing. With the elimination diagnosis particularly in the rearfoot Diagnostic imaging includes ra - of pain, the forces should be suffi - and midfoot; and the use of imaging diographic evaluation, technetium-99 ciently low for healing and remodel - should be considered. 41 bone scan, and MRI. Often, an injury ing to take place. Weight-bearing ex - On the tibia, as is mentioned else - where in this article, a horizontal line of tenderness is often the differentiat - Conservative treatment works well for most RSI ing clinical sign from the vertical ten - derness of medial tibial stress syn - of bone. The key is finding the appropriate mechanical drome. Immobilization in a pneumatic walker for four to six weeks or more treatment to eliminate the pain of weight bearing. is often helpful for tibial stress frac - tures, and a variety of other stress in - juries of bone. 42 Calcaneal stress frac - is not visible on radiographic exami - ercise should be avoided. Multiple au - tures may be suspected when there is nation. Bone scintigraphy is consid - thors have recommended the use of a tenderness upon lateral compression ered sensitive, while MRI is consid - pneumatic walker for tibial stress of the body, rather than at the medial ered to be both sensitive and specif - fractures. 42,45 This may be used alone calcaneal tuberosity or tenderness that ic. 41 At early stages, the MRI shows or with crutches, as needed. A cam is only plantar to the calcaneus. marrow edema as an increased STIR walker, pneumatic walker or low In a group of military recruits, the signal and in fat-suppressed T2 im - pneumatic walker may alleviate pain majority (56%) of calcaneal stress re - ages. On T1 sequences, a decreased faster and is often clinically superior actions occurred in the posterior third signal is noted. 44 As the injury pro - to a post-operative shoe for stress re - of the bone and 79% occurred in the gresses to a stage of increasing severi - actions of the metatarsal area, and for upper half of the calcaneus. 43 Earlier ty, a low signal fracture line and bone other foot stress reactions. reviews noted that the injury oc - callus may be visible. During recovery, one should guide curred primarily in the posterior as - A number of conditions may ap - the athlete to appropriate cross-train - pect of the calcaneus, but Sormaala pear similar to stress fracture on cer - ing activity. Swimming, bicycling, and notes the importance of suspecting a tain imaging studies (Table 7). In other maintenance of upper body strength should be implemented. Lower ex - tremity exercises should be chosen as TABLE 7 appropriate, and if deemed to not risk delayed healing or further injury. Differential Diagnosis of Lower A phased return to activity, allow - ing sufficient time for healing, is the Extremity Stress Fracture key to a successful return to activity. In clinical practice, the author has Conditions that may appear to be a stress fracture found that weaning from the pneu - matic walker seems to lessen the time Patellofemoral pain syndrome to comfortable exit from the walker Osteoid osteoma and prevent pain from returning and the necessity of returning to the use Osteomyelitis of the pneumatic walker. Most lower- Osteosarcoma extremity stress reactions take be - Ewing Tumor tween 8 and 17 weeks for recovery. 38 Bone metastases Osteochondral fracture Medial Tibial Stress Syndrome Accessory Navicular (painful) (Shin Splints) Inflammatory disorders Shin splints, the term that just Medial Tibial Stress Syndrome won’t die, is still on the frequent in - jury list, but now under a different Continued on page 184 www.podiatrym.com JUNE/JULY 2013 | PODIATRY MANAGEMENT | 183 n ng io SPORTS PODIATRY ui at in c t du RUNNING INJURIES on E C al ic ed M name.. The terms anterior shin splints, posteromedial shin splints, and a host of other terms came into TABLE 8 vogue in the 1970’s and 1980’s. As long ago as 1967, Slocum encouraged Pribut Pain Staging of the abandonment of the term shin splints from the medical literature. 46 Overuse Injuries in Athletes Ten years later, James also supported the efforts to eliminate the term sug - Stage 0 —No pain is present before, during or after activity. Minor gesting posterior tibial syndrome as discomfort may be experienced at various times during training or an alternative. 47 racing. The improved descriptive term medial tibial stress syndrome is now Stage 1 —Pain or stiffness after activity. The pain is usually gone by in common use. The term was first the next day. applied by R. Drez and popularized 48 by Mubarak in 1982. This term is ap - Stage 2 —Mild discomfort before activity that goes away soon after propriate to use in the absence of a exercise is commenced. No pain is present in the latter part of the stress fracture or an exertional com - partment syndrome. The older term, exercise. Pain returns after the exercise is completed (starting within shin splints, never made clear what 1 to 12 hours later and lasts up to 24 hours). part of the leg was affected. Some have considered the shin to be the Stage 3 —Moderate pain is present before sport. Pain is present dur - front part of the leg below the , ing sport activity, but is somewhat decreased. The pain is an annoy - the front part of the tibia, or the lower ance which may alter the manner in which the sport is performed. leg itself. We will omit consideration of anterior tibial leg pain and review Stage 4 —Significant pain before, during, and after activity. The pain the medial portion of the tibia that the may disappear after several weeks of rest. term medial tibial stress syndrome (MTSS) refers to. Stage 5 —Pain before, during, and after activity. The athlete has Historically included entities with - in the realm of MTSS include: perios - stopped their sports participation because of the severity of the pain. titis, traction periostalgia, tendinopa - The pain does not abate completely even after weeks of inactivity. thy, periosteal reaction, and fatigue failure of the connective tissue con - necting muscle to bone. 49 sense. He notes elsewhere in his arti - border of tibia; cle that the pain in the early stages 4) Pronated feet; Where is the Pain? Symptoms and does fade with rest. Previous observa - 5) Normal x-ray films. Description tions of overuse injuries and pain- By definition, the pain in MTSS staging better and more accurately de - Risk Factors occurs at the posteriomedial aspect of fine the pain seen with this Thacker 49 reviewed the available the tibia. Edwards has detailed an al - condition. 51-53 See Table 8 for a staging epidemiological literature and found a gorithmic approach to diagnosis and of pain occurring in overuse injuries. general consensus that there were a confirmatory tests to differentiate Nerve compression or entrapment variety of potential risk factors de - MTSS from nerve injury and compart - syndromes are usually considered tailed in the literature. The risk fac - ment syndrome. 50 He suggests that when the history includes the descrip - tors most often cited include: younger MTSS may occur more often in the tion of pain that is burning in nature age, female gender, change in dis - distal third of the tibia, and one and may be associated with a subjec - tance, frequency, speed, surface of should consider stress fracture more tive or objective observation of numb - runs, change of running shoes, excess proximally. While his flow chart is in - ness. Exertional compartment syn - pronation, and a previous history of teresting, it is severely flawed. MTSS dromes, which present with a some - injury. As is often the case in the is considered as a strong possibility what different set of symptoms, will medical literature, contrary studies with pain at rest in the presence of not be reviewed within this paper. are often found. Contrary studies are palpable tenderness. In the absence of Michael and Holder 54 described also cited on age, gender, mileage, pain at rest, but with palpable tender - the clinical characteristics of early hill running, running surface, previ - ness, he considers common or super - MTSS as including: ous activity level and flexibility. In ficial nerve entrapment as the likely 1) Induced by exercise, relieved our constant quest for high level stud - cause of lower limb pain. by rest; ies that are reliable and meet the re - Unfortunately, in the context of 2) Dull ache to intense pain; quirements of evidence-based treating runners, this makes little 3) Tenderness posterior medial Continued on page 185

184 | JUNE/JULY 2013 | PODIATRY MANAGEMENT www.podiatrym.com M C SPORTS PODIATRY e o di n ca ti l nu RUNNING INJURIES E in du g ca ti on medicine, we often find ourselves bulk of the tenderness is usually cise programs. There are a num - wandering in the mire of the litera - noted clinically. Beck and Osternig ber of possible experimental de - ture and decide that the evidence is performed cadaver dissections which sign measures that might show differ - thin for much of what we think we demonstrated that the soleus, flexor ences better, but at this point the evi - know. We remain with the knowl - digitorum longus and deep crural fas - dence that would back up common edge of the importance of having a cia were close to the usual areas in sense is not there. Thacker notes seri - basic understanding of causative fac - which symptoms were found and the ous “methodological flaws” in the tors in the context of carefully assess - posterior tibialis muscle was found a studies he reviewed. 49 ing an individual patient. considerable distance proximally. 58 In It is important to include rest and spite of the downplaying of the tib - relative rest at the top of recommen - Imaging ialis posterior by its anatomical posi - dations. Two to four weeks of rest While clinical signs and symp - tion, under eccentric contraction, may alleviate much of the pain in toms will lead you to the diagnosis in Pribut postulates that it should still early MTSS. Training alterations many cases, it still may be helpful to substantially increase the strain in the prior to the development of MTSS rule out a stress fracture. Radiographs medial tibia. need to be carefully analyzed and should be taken in questionable Bouché and Johnson researched recommendations should be made cases, but they are often insufficiently traction resulting upon the tibial fas - based upon this analysis. A biome - sensitive to show many stress frac - cia when forces are applied to the chanical analysis of the lower ex - tures and offer no information that posterior tibial, soleus, and flexor dig - tremity should be performed, and would demonstrate MTSS. itorum longus tendons. 59 In their dis - shoe and custom orthotic recommen - Both triphasic bone scans (dif - cussion, they noted that these mus - dations are made as needed. 50 Exces - fuse, superficial, linear uptake) and MRI (diffuse linear signal on T2) have been used to demonstrate stress frac - It is important to include rest and relative rest ture and, in many cases, they may demonstrate linear patterns suggest - at the top of recommendations. Two to four weeks of rest ing MTSS; although negative studies do not preclude the diagnosis of may alleviate much of the pain in early MTSS. MTSS.

MTSS—Causes cles eccentrically contract during sive pronation has been found to be There are a variety of theories of stance to counter midtarsal and subta - a contributing factor. the pathogenesis of MTSS. Periostitis lar pronatory forces, which earli - NSAIDS, while not directly ad - was one widely believed to be the er had been linked to MTSS. 60 Bouché dressing , are useful ad - cause of the pain, but histologically and Johnson’s study demonstrated a juncts to pain control and allow the inflammation was not found. 55 Pe - direct linear relationship between early resumption of normal motion riostalgia has been applied to pain at forces applied to those muscles and patterns and strengthening and this site in the absence of inflamma - strain measured at the muscle bone stretching exercises. Gastrosoleus tion. Johnell, et al., found metabolic interface, and the conclusion they stretching should be undertaken. Core changes in bone with no inflamma - reached was that “eccentric contrac - muscle strengthening is becoming in - tion and believed MTSS to be a stress tion of the superficial and deep flexor creasingly used for a variety of lower reaction of bone. Other theorists have tendons of the leg is the key pathome - extremity overuse injuries and should proposed traction injury at the poste - chanical factor …” in the creation of be evaluated for strength deficit. rior tibialis and/or soleus muscles. 54 MTSS. 59 Bouché also noted that exer - During the rest period, the athlete Bates in 1985 postulated that ex - cising on hard floors had been found will need to be given a program of al - cessive pronation and eccentric con - to increase eccentric contractions of ternative exercise. This may consist of traction of the soleus and posterior these muscles. The research of low impact cardiovascular exercises tibial muscles were contributing fac - Bouché sits well with the concepts such as swimming, stationary bicycle, tors in the development of MTSS. 56 earlier espoused by Michael, et al. in or pool running. It may be supple - Factors that increase bending mo - their article entitled “The Soleus Syn - mented with upper body weight train - ments or traction at these sites in - drome.” 54 Michael’s suggestion that ing. Gradual return to activity and in - clude a planus foot type, tarsal coali - the soleus could contribute to “shin crementally building up distance and tion, leg length inequality, and mus - splints” was based on cadaver, EMG, intensity should assist in a smooth re - cle imbalance. 57 and muscle stimulation research. turn to normal activity. The tibialis posterior muscle ori - gin has been noted to be in the upper Treatment and Prevention Plantar Fasciopathy, Plantar Heel two thirds of the interosseus mem - Thus far, a number of studies Pain Syndrome brane, medial fibula, and lateral tibia. have surprisingly failed to show pre - is one of the most It is somewhat proximal to where the vention from graded increase in exer - Continued on page 186 www.podiatrym.com JUNE/JULY 2013 | PODIATRY MANAGEMENT | 185 n ng io SPORTS PODIATRY ui at in c t du RUNNING INJURIES on E C al ic ed M frequently found foot injuries found no inflammation present. In - absence and presence of an inferior among runners. As with several stead, he found changes analogous to . other entities, we are discovering that that found in tendinosis: myxoid de - The origin of the plantar is many of the terms we have called generation, collagen degeneration, in - an enthesis similar to the Achilles this by are likely incorrect. The heel creased vascularization, and vascular tendon. Fibrocartilage is found at its pain we most often see has been engorgement of the adjacent bone site of origin. Growing heel spurs ap - called many things including plantar marrow. 62 Evidence of inflammation pear to take shape deep to the plan - heel pain, heel spur syndrome, and was not seen. While Lemont indicat - tar fascia and have been noted to recently plantar heel pain syn - ed that plantar fasciitis should be con - grow within developing cartilage via drome. 61 In the term fasciitis, the -itis sidered plantar fasciosis, this latter endochondral and intramembranous ending denotes an inflammation. Per - term is probably best termed fasciosis ossification, most likely at the site of haps if we redefined -itis, we could after biopsy, and plantar fasciopathy the enthesis and in close association still use fasciitis and tendonitis, but is a more suitable term. with the flexor digitorum brevis. 63 the death of the term plantar fasciitis The term plantar heel pain syn - Recent thinking is that this is not a is rapidly approaching. drome can be used to include condi - traction injury but an Lemont examined specimens and tions of pain in this region in both the formed in the enthesis via stimula - tion of the bone by stress. Pribut has hypothesized that even in the ab - TABLE 9 sence of direct traction injury at the site of origin of the , Selected Entities Causing there will be sufficient strain in the enthesis and in the calcaneus to Plantar Heel Pain stimulate bone and cartilage produc - tion and sufficient strain to also cre - Mechanical ate other calcaneal stress injuries. Plantar Fasciopathy Early changes occurring in the enthe - Plantar sis fibrocartilage near the calcaneal Muscle strain at origin of quadratus plantae, abductor hallucis, surface include the appearance of cartilage cell clusters and longitudi - or flexor hallucis brevis nal fissure formation with erosion of subchondral bone. Repetitive Trauma Most spurs develop deep to the Stress fractures plantar fascia in the flexor digitorum Rupture of plantar fascia brevis, quadratus plantae and abduc - Heel pad atrophy tor hallucis muscle origins. 63a It is logi - cal to conclude that the muscles origi - Neurological nating in this area, especially the Posterior tibial nerve—tarsal tunnel syndrome quadratus plantae, may play a signifi - Medial calcaneal nerve cant role in the plantar heel pain syn - Medial plantar nerve drome. The other intrinsic muscles are also likely to be involved in this Lateral plantar nerve syndrome. Unfortunately, this is not Peripheral neuropathy often discussed or considered in arti - Discogenic pain cles and lectures on “plantar fasciopa - Central nervous system lesion thy.” Discussion and debate is often limited to “the spur is not in the fas - Arthritic cia”, “vertical forces might be in - Seronegative Spondyloarthropathies volved rather than traction” and Rheumatoid Arthritis “does the spur cause the pain”? The Fibromyalgia real questions are “what is the totality Gout of structures contributing to the Enthesopathy pain?”, “what role do the intrinsic muscles play both in the development of pain and production of the heel Misc. spur?” , “what does it mean that Infection much of the anatomy in this area is a Bone cyst or tumor part of an enthesis?”, and “what Apophysitis should we do to eliminate the pain, Continued on page 187

186 | JUNE/JULY 2013 | PODIATRY MANAGEMENT www.podiatrym.com M C SPORTS PODIATRY e o di n ca ti l nu RUNNING INJURIES E in du g ca ti on recommended a custom orthot - ic. Corticosteroid injections were TABLE 10 also frequently recommended—al - though, in view of Lemont’s findings, Outline of Treatment the rationale of such injections needs to be reconsidered. 62 The increased Recommendations for Plantar risk of rupture of the plantar fascia Heel Pain Syndrome following both corticosteroid injection and exercising after these injections should also be taken into considera - Relative or Absolute Rest tion. Night splints were also some - Calf Stretching times used. Intrinsic muscle strengthening (towel toe crunches, marble pick-ups, etc.) Additional measures recommend - Cryotherapy ed for late stage plantar fasciopathy NSAIDs (for pain, not inflammation) include immobilization via the use of Night splints a cast or pneumatic walker, plantar OTC Insert fasciotomy, and extracorporeal shock - Custom Foot orthoses wave therapy. Shoes—with increased torsional & flexion stability Plantar fascia rupture is not a com - Check Stability of running and walking shoes, replace if necessary monly found running injury. When this occurs it is readily treated with Avoid barefoot walking pneumatic cast boot immobilization Avoid calf raises and stair dips and other forefoot-only contact exercises using pain as a guide as to when weight bearing should be permitted. Generally 6 –8 weeks of immobilization improve function, and keep our run - Treatment followed with an orthotic and rehabili - ners on the road?” Entire issues and seminars are de - tative exercises works well. This voted to plantar heel pain and its method has been used in our offices Symptoms treatment. We will briefly review cur - for over 25 years. A similar method Pain upon arising in the morn - rent therapy. A survey of members of was detailed in 2004 by Saxena and ing is one of the hallmarks of plan - the American Academy of Podiatric Fullem with a study of over 18 cases. 62a tar heel pain syndrome. The pain is Medicine detailed the most common It is important to examine your noted to be on the plantar or plantar treatments that they employ for plan - patient’s running shoe to make cer - medial aspect of the heel. Tender - tar heel pain syndrome. 61 Recommen - tain that flexion and torsional stability ness is usually found upon palpa - dations based on this survey and sub - is present. If the shoe is excessively tion of the medial calcaneal tuberos - sequent observations follow. flexible, more forces will be created ity. It is important to distinguish For early heel pain of less than six within and near the plantar fascia, plantar fasciitis from a tear of the weeks duration, the most frequent most likely via the windlass effect. If plantar fascia, which most often oc - recommendations were for avoidance the pain has been severe enough to cause the patient to miss several weeks’ worth of running, a slow and It is important to examine your patient’s gradual return is important to avoid recurrence of injury or a new overuse running shoe to make certain that flexion and injury. Intrinsic muscle strengthening and calf muscle stretching need to be torsional stability is present. performed by the athlete regularly. An outline of treatment recommenda - tions follows in Table 10. curs 2-6 cm anterior to the origin of of walking barefoot or walking in flat the plantar fascia and from a cal - shoes, over the counter inserts, regu - An Unusual Presentation caneal stress fracture. The tender - lar calf stretching, cryotherapy, non- of Heel Pain ness of most calcaneal stress frac - steroidal, anti-inflammatory drugs Sometimes the very rare and dan - tures is linear and found on the (NSAIDs), and strapping of the foot. gerous can masquerade as the ordi - body of the calcaneus, often on both Toe crunches or marble pickups de - nary and simple. A middle aged run - the medial and lateral sides. Nerve signed to improve the strength of the ner presented to my office with a entrapment may also cause pain in intrinsic muscles should be started. complaint of burning pain in his heel this region. Table 9 details some of At an intermediate stage, when which occurred at random times. No the clinical entities that can cause pain has been present for six weeks to local tenderness was found. No plantar heel pain. six months, the respondents usually Continued on page 188 www.podiatrym.com JUNE/JULY 2013 | PODIATRY MANAGEMENT | 187 n ng io SPORTS PODIATRY ui at in c t du RUNNING INJURIES on E C al ic ed M Tinel’s sign was found nor was menschlichen fussess. 1855; 24:169-177. ning Injuries. Podiatry Management, 2004. referred pain found in examination Medizin Zeitung, 1855. 24: p. 169-177. 23(1): p. 57-68. of the tarsal tunnel area. The burning 37 Stechow, Fussödem und Röntgen - 54 Michael, R.H. and L.E. Holder, The was taken to be evidence of a neuro - strahlen. Deutsche Militärärztliche Soleus Syndrome. Am J Sports Med, 1985. logical problem, possibly at the level Zeitschrift, 1897. 26: p. 465. 13(2): p. 87-94. 38 Matheson, G.O., et al., Stress frac - 55 Detmer, D.E., Chronic shin splints. of the spinal nerves (although tarsal tures in athletes. A study of 320 cases. Am J Classification and management of medial tunnel syndrome was a lesser consid - Sports Med, 1987. 15(1): p. 46-58. tibial stress syndrome. Sports Med, 1986. eration). The patient was referred to a 39 Akkus, O. and C.M. Rimnac, Cortical 3(6): p. 436-46. neurologist for evaluation. The neu - bone tissue resists fatigue fracture by decel - 56 Bates, P., Shin splints—a literature re - rologist felt the ocular examination to eration and arrest of microcrack growth. J view. Br J Sports Med, 1985. 19(3): p. 132-7. be most significant. Upon ocular ex - Biomech, 2001. 34: p. 757-764. 57 Sommer, H.M. and S.W. Vallentyne, amination, increased intracranial 40 Lebrun, M., The Female Athlete Effect of foot posture on the incidence of pressure was suspected. A brain scan Triad: What’s a Doctor to Do? Current medial tibial stress syndrome. Med Sci revealed a lesion in the cerebral cor - Sports Medicine Reports, 2007. 6: p. 397- Sports Exerc, 1995. 27(6): p. 800-804. 58 tex (near the sensory region). The le - 404. Beck, B.R. and L.R. Osternig, Medial 41 Niva, M.H., et al., Bone stress injuries tibial stress syndrome. The location of mus - sion was a well-differentiated glioma. of the ankle and foot: an 86-month magnetic cles in the leg in relation to symptoms. J Within the first month following resonance imaging-based study of physically Bone Joint Surg Am, 1994. 76(7): p. 1057- surgery, the symptoms were no bet - active young adults. Am J Sports Med, 2007. 1061. ter. As recovery proceeded following 35(4): p. 643-9. 59 Bouche, R.T. and C.H. Johnson, Me - the surgery, within 3 months the heel 42 Swenson, E.J., et al., The Effect of a dial Tibial Stress Syndrome (Tibial Fasci - pain symptoms abated and have not Pneumatic Leg Brace on Return to Play in itis): A Proposed Pathomechanical Model returned after 5 years. It is unlikely Athletes with Tibial Stress Fractures. Am. J. Involving Fascial Traction. J Am Podiatr you’ll ever see a case like this. But Sports Med., 1997. 25(June): p. 322-328. Med Assoc, 2007. 97(1): p. 31-36. 43 60 you are likely to see something rare in Sormaala, M.J., et al., Stress Injuries Viitasalo, J.T. and M. Kvist, Some your practice. Keep your eyes open of the Calcaneus Detected with Magnetic biomechanical aspects of the foot and ankle Resonance Imaging in Military Recruits. J in athletes with and without shin splints. and your mind ready. Bone Joint Surg Am, 2006. 88: p. 2237-2242. Am J Sports Med, 1983. 11(3): p. 125-30. 44 Stafford, S.A., D.I. Rosenthal, and 61 Pribut, S.M., Current Approaches to Summary M.C. Gebhardt, MRI in Stress Fracture. AJR the Management of Plantar Heel Pain Syn - The study and quest for under - Am J Roentgenol, 1986. 147: p. 553-556. drome, Including the Role of Injectable Cor - standing athletic injuries is a lifelong 45 Fredericson, M., et al., Tibial stress ticosteroids J Am Podiatr Med Assoc, 2007. undertaking. We have tried to give a reaction in runners. Correlation of clinical 97(1): p. 68-74. picture of some of the most common symptoms and scintigraphy with a new 62 Lemont, H., K. Ammirati, and N. running injuries in this article and to magnetic resonance imaging grading sys - Usen, Plantar Fasciitis A Degenerative Pro - detail the evolution of thought that tem. Am J Sports Med, 1995. 23(4): p. 472- cess (Fasciosis) Without Inflammation. J has occurred over the last few 81. Am Podiatr Med Assoc, 2003. 93(3): p. 234- 46 Slocum, D.B., The shin splint syn - 237. decades on these commonly seen drome. Am J Surg, 1967. 114: p. 875-881. 62a Saxena A, Fullem B., Plantar fascia clinical entities. We hope your inter - 47 James, S.L., B.T. Bates, and L.R. Os - ruptures in athletes. Am J Sports Med. 2004 est has been piqued to continue learn - ternig, Injuries to Runners. Am J Sports Apr-May;32(3):662-5. ing about these maladies and that you Med, 1978. 6: p. 40-50. 63 Kumai, T. and M. Benjamin, Heel develop a method of assessing the lit - 48 Mubarak, S.J., et al., The Medial Tib - spur formation and the subcalcaneal enthe - erature to better treat your patients. ial Stress Syndrome: A Cause of Shin sis of the plantar fascia. J Rheumatol, 2002. To enhance your knowledge of sports Splints. Am J Sports Med, 1982. 10(4): p. 29(9): p. 1957-64. medicine in a face-to-face setting, I 201-205. 63a Smith S, Tinley P, Gilheany M, Grills 49 encourage you to attend lectures on Thacker, S.B., et al., The prevention B, Kingsford A. The inferior calcaneal these topics. Venues which include of shin splints in sports: a systematic review spur—anatomical and histological consider - of literature. Med Sci Sports Exerc, 2002. ations. Foot. 2007;17:25-31. doi: information of interest to the podiatric 34(1): p. 32-40. 10.1016/j.foot.2006.10.002. sports medicine physician include the 50 Edwards, P.H., M.L. Wright, and J.F. Annual APMA Scientific Seminar fea - Hartman, A Practical Approach for the Dif - turing a track put on by the AAPSM, ferential Diagnosis of Chronic Leg Pain in Dr. Pribut is a Clinical regional meetings which feature the the Athlete. Am J Sports Med, 2005. 33: p. Assistant Professor of AAPSM and a variety of lecture series 1241-1249. Surgery at George at the podiatric medical colleges 51 MacIntyre, J.G., J.E. Taunton, and Washington University which are jointly put on with the D.B. Clement, Running injuries: a clinical Medical School. He AAPSM. Information on these meet - study of 4,173 cases. Clin J Sport Med, serves on the Runner’s World Board of Advi - ings can be found at the website of 1991. 1(2): p. 81-87. 52 O’Connor, F.G., T.M. Howard, and sors. He is a past presi - the AAPSM (www.aapsm.org). PM C.M. Fieseler, Managing Overuse Injuries: A dent of the American Systematic Approach. Physician & Academy of Podiatric References Sportsmedicine, 1997. 25(5): p. 11. Sports Medicine. Dr. Pribut is in private practice 36 Breithaupt, J., Zur pathologie des 53 Pribut, S.M., A Quick Look At Run - in Washington, DC.

188 | JUNE/JULY 2013 | PODIATRY MANAGEMENT www.podiatrym.com M C e o di n ca ti l nu E in CME EXAMINATION du g ca ti on SEE ANSWER SHEET ON PAGE 191 .

1) Stress fractures occurring in 7) Evidence in studies has 12) The histological findings of the lower extremity in runners indicated that a large contribut - tendinosis include: are best demonstrated using: ing factor to iliotibial band A) myxoid degeneration A) a bone scan syndrome is: B) parakeratosis B) computed tomography A) weak abductor C) inflammatory exudates C) x-ray muscles D) copius lymphocytes D) tuning fork B) over pronation of the foot C) high arches 13) Stress fractures of the tibia 2) Diffuse activity along the poste - D) low blood levels of do not usually demonstrate: riomedial aspect of the tibia visi - Vitamin D A) horizontal line of ble on bone scintigraphy probably tenderness indicates: 8) The pain of iliotibial band syn - B) diffuse linear vertical A) osteogenic sarcoma drome is most often experienced uptake on scintigraphy B) stress fracture in the region of the: C) negative findings on C) medial tibial stress A) anterior knee x-ray syndrome B) posterior aspect of the D) focal area of concentrated D) osteomyelitis knee uptake in proximal 1/3 of C) medial aspect of the knee tibia on scintigraphy 3) In reference to the impact on D) lateral aspect of the knee. the patellofemoral complex, the 14) In the detection of stress vastus medialis oblique is: 9) The most frequently occurring fractures of the lower extremity, A) a static stabilizer Achilles tendon injuries in run - the following imaging study B) a dynamic stabilizer ners are best termed is considered sensitive and C) a passive stabilizer A) Achilles tendonitis specific: D) a destabilizer B) Achilles heel A) Te-99 Bone Scinigraphy C) Achilles B) MRI 4) The patella has the least D) Achilles tendinopathy C) Ultrasound amount of medial stability at: D) X-ray A) zero degrees of flexion 10) All of the following types B) 20 degrees of flexion of footgear could aggravate pain 15) Pain and tenderness at the C) 45 degrees of flexion in the Achilles tendon area posteriomedial aspect of the D) 90 degrees of flexion. except: tibia in runners: A) zero drop, minimalist shoes A) is best treated with corti - 5) Factors considered important to and a switch to forefoot con - costeroid injections the development of patellofemoral tact running style B) is most often a stress pain syndrome include: B) firm heel shoe, flexible at fracture A) abnormal pronation of the ball, with 1/4” heel lift C) is caused by a tight or a foot C) well-cushioned shoes weak anterior tibialis B) patella alta D) shoes with a stiff and hard- muscle C) weak hip abductor muscles to-bend sole. D) often falls into the catego - D) all of the above. ry of posterior tibial stress 11) The insertion of the Achilles syndrome 6) Pain that develops after run - tendon and the plantar fascia are ning in the anterior region of a pa - similar in that they both: 16) The following statement tient’s knee is most likely to be A) insert into the talus about patellofemoral pain disor - what is appropriately termed: B) are both improved with stiff der is false: A) Runner’s Knee running shoes A) the preferred name of this B) Patellofemoral pain syndrome C) are improved by jumping condition is anterior knee C) jacks and running in sand pain D) terrible triad D) are entheses Continued on page 190 www.podiatrym.com JUNE/JULY 2013 | PODIATRY MANAGEMENT | 189 n ng io ui at in c t du on E CME EXAMINATION PM’s C al ic ed M CPME Program

B) pronation of the foot has been found in Welcome to the innovative Continuing Education studies to be a risk factor Program brought to you by Podiatry Management C) studies indicate weak hip abductors to be Magazine. Our journal has been approved as a associated with PFPS sponsor of Continuing Medical Education by the D) the subchondral bone, extensor retinacu - Council on Podiatric Medical Education. lum and infrapatellar fat pad are possible sources of pain in PFPS. Now it’s even easier and more convenient to 17) All of the following statements about the enroll in PM’s CE program! Achilles tendon insertion are true except: You can now enroll at any time during the year A) Fibrocartilage is found at the insertion of and submit eligible exams at any time during your the Achilles tendon enrollment period. B) Sesamoidal cartilage is found at the inser - PM enrollees are entitled to submit ten exams tion of the Achilles tendon published during their consecutive, twelve–month C) periosteal cartilage is found at the inser - enrollment period. Your enrollment period begins tion of the Achilles tendon with the month payment is received. For example, D) articular cartilage is found at the insertion of the Achilles tendon if your payment is received on September 1, 2006, your enrollment is valid through August 31, 2007. 18) Surgical treatment of Achilles tendinosis If you’re not enrolled, you may also submit any most commonly would likely include any of the exam(s) published in PM magazine within the past following except: twelve months. CME articles and examination A) stripping of the paratenon questions from past issues of Podiatry Manage - B) excision of non-viable tissue ment can be found on the Internet at C) Gastrocnemius recession (e.g., Strayer http://www.podiatrym.com/cme. Each lesson is Procedure) D) linear tenotomy approved for 1.5 hours continuing education con - tact hours. Please read the testing, grading and pay - 19) The tibialis posterior muscle originates ment instructions to decide which method of par - from the: ticipation is best for you. A) distal medial aspect of the tibia Please call (631) 563-1604 if you have any ques - B) the proximal interosseus membrane, tions. A personal operator will be happy to assist you. medial fibula and lateral tibia Each of the 10 lessons will count as 1.5 credits; C) proximal 2/3 of the tibia only thus a maximum of 15 CME credits may be earned D) distal fibula and tibia during any 12-month period. You may select any 10 20) Although evidence based proof is weak, in a 24-month period. overuse running injuries are thought to be con - tributed to by all of the following except: The Podiatry Management Magazine CME A) carbohydrate loading program is approved by the Council on Podiatric B) overtraining Education in all states where credits in instructional C) shoes losing shock absorption and wearing media are accepted. This article is approved for down substantially 1.5 Continuing Education Contact Hours (or 0.15 D) starting marathon training never having CEU’s) for each examination successfully completed. run more than 20 minutes at a time

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