sign in sign up
<<
Home , Fasciitis, Ischial bursitis, Pes anserine bursitis, Plica syndrome, Shin splints, Snapping hip syndrome

REVIEW

KARA H. BROWNING, MD BRIAN G. DONLEY, MD Section of , Department of Section of and , Department of Orthopaedics, Cleveland Clinic; Department of Orthopaedics, Cleveland Clinic Orthopaedic , Euclid Hospital, Euclid, OH

Evaluation and management of common injuries

ABSTRACT T LEAST 25% OF ADULTS who run for sport or for pleasure suffer musculoskele- Adults who run for sport or for pleasure often present to tal injuries, and many present to an internist their primary care physician with musculoskeletal for evaluation. Prompt initial evaluation and complaints. Rapid diagnosis and conservative management management of these injuries is needed in the of common and referral of patients with primary care setting. This review focuses on injuries that have a propensity for morbidity, such as how to quickly evaluate the most common femoral stress fractures, are reviewed. Careful running injuries, which conservative treat- evaluation of the patient's running program and physical ments to apply, and when to refer the patient therapy are important components of management. for special treatment. • TAKING THE HISTORY KEY POINTS OF A RUNNING INJURY Sudden, significant changes in the training routine are the most frequent cause of injury in runners. Lack of rest As in many other areas of medicine, the between high-intensity workouts, a sudden increase in history is critical in assessing running injuries. When eliciting information about distance or intensity, and a workout that is too intense all symptoms, ask specifically about onset, contribute to injury. duration, precipitating factors, relieving factors, and prior treatment (FIGURE 1). Other Runners with stress fractures associated with a high risk of features to note are: morbidity should be referred to an orthopedic surgeon. biow long the patient has been running Competitive level Anterior is the most common complaint of Distance per week runners, and usually results from overuse rather than an Frequency acute injury. Type of terrain Warm-up and stretching routines Running does not cause , but running can Cross-training or supplemental activities Recent changes in running routine, shoes, accelerate its course. or terrain.

Common features of running injuries in adults Sudden, significant changes in the train- ing routine are the most frequent cause of injury in runners. Lack of rest between high- intensity workouts, a sudden increase in dis- tance or intensity, and a workout that is too intense all contribute to injury.

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 511 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. RUNNING INJURIES BROWNING AND DONLEY

Causes of common running injuries

Arm motion Excess motion across the trunk during running stresses the muscle insertions at the iliac crest, causing pain

Muscle condition Atrophy and contribute to overuse Reinjury injuries such as patellofemoral syndrome, A common problem in runners; Achilles tendonitis, and always ask about previous injuries

Genu valgum or varum May be associated with patellofemoral syndrome and osteoarthritis

Leg length Unequal leg length may contribute Shoe wear to hip or A running shoe's built-in and shock- absorbing structures wear out, and inflexible soles may overstress the lower leg; running shoes need to be replaced after about 300 miles of use Terrain — ie, about every 4 months for someone who Asphalt or concrete surfaces stress runs 20 miles per week the lower extremities more than cinders or grass CCF ©2000

FIGURE 1

Injuries tend to be due to overuse rather Beyond this point, increased force is transmit- than to acute damage. Particularly in the long- ted to the lower extremities. Most experts rec- distance runner, injuries are due more often to ommend changing running shoes after 300 overuse or insufficient tissue recovery after miles of use (eg, about every 4 months for repetitive stress than to acute injury. someone who runs 20 miles per week). Reinjury is a common problem in runners. Damage to the running shoe's built-in Always inquire about previous injuries. orthotics, inadequate heel counters, and Terrain can lead to injury. Running on inflexible soles can lead to symptoms. asphalt or concrete stresses the lower extremi- ties more than running on cinders or grass. The • THE evenness of the surface and the camber are additional factors that may lead to muscu- The physical examination should include both loskeletal injury. an evaluation of the affected part and a general Shoes are very important. The shock- biomechanical evaluation, looking for evidence absorbing ability of most running shoes—irre- of scoliosis, genu valgum or varum, unequal leg spective of the cost or material—is diminished length, muscle atrophy, and muscle contractures by at least 30% after 500 miles of use.1'2 (FIGURE 1). Gait should be assessed,3-5 and run-

512 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. Brief overview of common running injuries in adults

Apophysitis of the iliac crest is caused Trochanteric is characterized by by excessive arm motion across the trunk, tenderness along the posterior aspect of increasing the stress at the muscle the greater trochanter insertions along the crest

Snapping hip syndrome is characterized by hip pain and an audible snap heard Stress fractures may occur in the hip, when the flexed, abducted, and externally pelvis, , and femoral neck, and female rotated femur is extended endurance athletes are at increased risk

Ischial bursitis or insertional tendonitis of the presents as pain exacerbat- ed by sprinting, running on hills, or pro- longed sitting

Anterior knee pain accounts for at least 29% of all running injuries. The includes patellofemoral syndrome, chondromalacia, , bursitis, and tendonitis of the quadriceps or patella lliotibial band friction syndrome produces lateral knee pain due to friction of the band gliding over the lateral femoral condyle with repetitive knee flexion and Tibial is differentiated extension from shin splints by pain that persists after the run, night pain, and pain during walking

Shin splints (medial tibial stress syndrome) occur with exercise and are relieved with rest Calcaneal stress fracture should be ruled out when considering a diagnosis of fat pad syndrome

Metatarsal stress fractures in runners usually occur in the second Achilles tendonitis is caused by metatarsal bone and usually heal without repetitive impact, excessive pronation of complication the foot, tightness of the Achilles complex, and changes in running routine

Fat pad syndrome presents as central Plantar presents as inferior heel heel pain caused by repetitive trauma, pain with the first step of the day. Heel direct trauma, or corticosteroid injection spurs are associated with but do not cause it CCF ©2000

FIGURE 2

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 513 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. RUNNING INJURIES BROWNING AND DONLEY

ning shoes should also be inspected. Careful is characterized inspection for asymmetry may help to direct the by hip pain and an audible snap on exten- examination. In general, shoes should be sion of the leg from a flexed, abducted, inspected for an adequate heel wedge, forefoot externally rotated position. Back pain may cushioning, and medial arch support. also be reported. The syndrome is caused by When evaluating the pain, ask the patient the snapping of the iliotibial band over the to describe where it hurts and when it occurs greater trochanter. Repetitive friction in during the workout, since both are important this region may result in trochanteric bursi- to the differential diagnosis. tis. FIGURE 2 provides a basis for the following Treatment of both conditions consists overview of common running injuries. of relative rest (ie, avoiding activities that exacerbate symptoms), stretching the ili- • HIP, PELVIS, AND THIGH otibial band, strengthening the trunk and INJURIES IN RUNNERS hip girdle musculature, and nonsteroidal anti-inflammatory drugs (NSAIDs). If Apophysitis symptoms persist, then consider injection of Apophyseal injuries occur in the skeletally the bursa with a local anesthetic and a cor- immature patient at a tendon insertion site. ticosteroid. Apophysitis of the iliac crest may present subacutely as an overuse syndrome in runners. or irisertional tendonitis It is caused by excessive arm motion across the Ischial bursitis or Lnsertional tendonitis of the trunk, which increases the stress at the muscle hamstring musculature may present as pain in insertions along the crest. On examination the buttock or posterior thigh. Pain is usually there is tenderness to palpation of the iliac exacerbated by sprinting, running on hills, or crest, and resisted abduction of the affected prolonged sitting. Driving a car may be partic- hip reproduces the pain. The condition is pre- ularly troublesome. Treatment consists of vented by limiting excessive arm swing across stretching, icing, NSAIDs, and use of a foam Reinjury is the trunk. donut for sitting. Consider corticosteroid common: Apophysitis of the anterior superior iliac injection for refractory cases. spine and anterior inferior iliac spine can always inquire occur in adolescent sprinters. Both present Stress fractures of the hip, pelvis, thigh about previous with the sudden onset of pain in the groin or Stress fractures may occur in the hip, pelvis, or anterior hip. thigh when the bone fails to adapt to the injuries Apophysitis of the ischial tuberosity is mechanical loads placed on it. Stress fractures another problem seen mainly in adolescent can occur either when abnormal stresses are athletes. It may occur acutely and present as applied to normal bone or when normal stress- pain at the tuberosity. es are applied to abnormal bone. Treatment of most apophyseal injuries Female endurance athletes in particular consists initially of protection, icing, and anal- are at an increased risk for amenorrhea (result- gesics, followed by exercises to recover range ing in a hypoestrogenic state) and stress frac- of motion and strength. tures. Stress fractures of the pubic ramus may occur in long-distance runners and are more Trochanteric bursitis common in women. In most cases, a careful Trochanteric bursitis is a common complaint history will reveal a change in the training in runners. It presents as lateral hip pain exac- routine as the contributing factor; however, it erbated by activity. tendonitis is also important to consider underlying meta- should be considered in the differential diag- bolic or endocrine disorders. nosis.1 Bursitis results in tenderness to palpa- Symptoms and examination. Symptoms tion along the posterior aspect of the greater include pain in the inguinal, perineal, or trochanter. In contrast, gluteus medius ten- adductor region, which is relieved by rest and donitis will result in tenderness to palpation exacerbated by activity.6 Hip range of motion above the greater trochanter. is usually normal. Pain is increased with

514 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. weight-bearing, and the patient may be unable Diagnostic tests. Radiographs will be pos- to stand on the affected extremity without itive after 2 to 4 weeks. A bone scan will con- support. The affected extremity is tender to firm the diagnosis. palpation. The patient often adopts a guarded Treatment consists of protected weight- (antalgic) gait to avoid the pain. bearing for 1 to 4 weeks, followed by gradual Diagnostic testing. Diagnosis is rarely resumption of activity. made with radiographs, but they should be obtained if a stress fracture is suspected. A pos- Osteoarthritis itive bone scan is diagnostic. Osteoarthritis may be a source of hip or groin Treatment consists of protected weight- pain in runners. Congenital hip dysplasia may bearing (using crutches when walking) for 4 predispose a person to osteoarthritis and is to 6 weeks, followed by a gradual return to often undetected until he or she presents with activity. Recovery generally takes 3 to 5 premature degenerative changes. months. It is critical that adequate recovery Symptoms and examination. The patient periods are allowed once activity is resumed. usually complains of groin pain that is worse Follow-up radiographs may show an abun- after activity and, sometimes, is accompanied dant callus, which should not be confused by morning stiffness. with malignancy. Treatment consists of modifying the run- ner's routine by adding cross-training activi- Femoral stress fractures ties with reduced loading, such as swimming Stress fractures of the femoral neck are poten- or stationary biking, by changing to a softer tially serious, carrying the risk of avascular surface such as cinders, by strengthening the necrosis and deformity. hip girdle musculature, and by giving Symptoms and examination. The patient NSAIDs. presents with groin, anterior thigh, or knee pain. Pain occurs toward the end of range of • KNEE INJURIES IN RUNNERS motion, especially with internal rotation and flexion. The gait may be antalgic, and a single Anterior knee pain Most running leg-hop test will reproduce symptoms. Anterior knee pain is the most common com- injuries respond Diagnostic testing. Radiographs are usual- plaint in runners, accounting for at least 29% ly not positive for 2 to 4 weeks. A bone scan of all injuries.3-10 As with most knee problems to rest, icing, or magnetic resonance imaging (MRI) is rec- in runners, it is an overuse injury rather than NSAIDs, ommended in runners with a suggestive histo- an acute injury. ry and negative radiographs. The differential diagnosis includes stretching, and Stress fractures of the femoral neck can patellofemoral syndrome, chondromalacia, strengthening occur in the superior cortex or the inferior cor- plica syndrome, bursitis, and tendonitis of the tex of the femoral neck. Fractures of the supe- quadriceps and patella. Patellofemoral syn- rior cortex have a high risk of displacement drome is a general term for pain at the and subsequent nonunion, delayed union, patellofemoral articulation. Chondromalacia avascular necrosis, and deformity; therefore, is a specific condition in which the articular surgical fixation is the treatment of choice. cartilage is softened and fibrillated. Fractures of the inferior cortex are usually Contributing factors. Abnormal tracking managed with protected weight-bearing and of the patella within the trochlea due to bio- gradual resumption of activity.7-9 However, mechanical abnormalities is thought to predis- owing to the morbidity associated with pose the runner to injury. Anatomic factors femoral neck fractures, referral to an orthope- include: dic surgeon is indicated. • Anteversion of the femur Stress fractures of the femoral shaft are • Tibial torsion less common and have a low complication • Subtalar pronation rate. Patients generally complain of vague • Widened Q-angle: ie, the relationship of thigh pain that worsens with activity. the patella to the anterior iliac spine and the Palpation may reveal local tenderness. tibial tuberosity (normal, 15°)

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 515 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. RUNNING INJURIES BROWNING AND DONLEY

• Muscle imbalance between the vastus tendonitis, tenderness to palpation is more medialis oblique muscles and the lateral pronounced with the knee extended rather quadriceps musculature than flexed, u • Decreased flexibility of the hip flexors, Treatment consists of a reduction in , gastrocnemius, and iliotibial intensity of training, avoidance of hilly ter- band. 10.11 rain, icing, NSAIDs, stretching, and strength Symptoms and examination. The runner enmg l presents with deep, aching anterior knee pain that worsens with prolonged sitting, stair Plica syndrome climbing, and running on hills. Examination Plica syndrome produces anterior-medial knee should include the entire lower extremity, pain. The plica is a congenital medial synovial with particular attention to patellar align- fold present in 60% to 80% of peopled ment and tracking, vastus medialis oblique Excessive friction of the plica over the medial muscle bulk, crepitus, and areas of tenderness. femoral condyle can produce a thickened and Excessive tightness of the lateral retinaculum fibrotic band of tissue, which may result in a may contribute to poor tracking and anterior snapping sensation. knee pain. Symptoms and examination. On exami- Diagnostic tests. Radiographs may not nation, the plica is palpable and tender, with always be required initially, but they should be localized tenderness over the medial femoral obtained if symptoms persist beyond 6 weeks condyle at the level of the medial border of of treatment or if the presentation is atypical. the patella. A snapping sound or crepitus may Radiographs should be taken during weight- be noted. An effusion is atypical and suggests bearing and should include anteroposterior, a mechanical etiology such as a chondral lateral, tunnel, and Merchant views. lesion, meniscal tear, or osteoarthritis. Treatment consists of icing, relative rest Resisted knee exercises may aggravate the with avoidance of squatting and stairs, and an condition.11 exercise program that emphasizes lower- Treatment consists of rest, icing, Anterior knee extremity flexibility and quadriceps strength- NSAIDs, stretching, and strengthening. pain is the most ening, particularly in terminal extension." Failure to respond to adequate conservative Strengthening should not produce pain. This measures is an indication for arthroscopic common regimen often is more effective when individ- excision.1 complaint in ualized under the guidance of a physical ther- apist.12 A "knee sleeve" or taping may relieve runners symptoms and facilitate rehabilitation. If Pes anserine bursitis produces medial knee anatomic abnormalities of the foot and ankle pain, usually distal to the line. The pes appear significant, the patient may benefit anserine is the common insertion of the sarto- from custom orthotics. rius, semitendinosus, and gracilis muscles into the medial . The condition may be con- Quadriceps tendonitis fused with a medial meniscal tear. and patellar tendonitis Symptoms and examination. Tenderness Quadriceps tendonitis and patellar tendonitis, at the insertion and pain with resisted flexion known together as "jumper's knee," can occur of the knee are diagnostic. in runners. Treatment. If conservative measures (rest, Symptoms and examination. Pain gener- icing, NSAIDs, stretching, strengthening) do ally occurs during a run but may not be severe not resolve the pain, corticosteroid injection enough to halt running. A key symptom of may be helpful. quadriceps tendonitis is tenderness of the insertion of the quadriceps into the proximal Osteoarthritis of the knee pole of the patella, whereas a key symptom of It is generally accepted that running does not patellar tendonitis is tenderness of the quadri- cause osteoarthritis, but once a runner devel- ceps insertion into the distal pole. Squatting ops osteoarthritis the running program should also frequently provokes the pain. In patellar be modified or discontinued because running

516 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. can accelerate the course of osteoarthritis. or may not be noted. Percussion proximal or If the patient is unwilling to abandon run- distal to the suspected fracture may reproduce ning, then changing the terrain, decreasing the pain. the distance, and substituting low-impact Diagnostic tests. Radiographic evaluation cross-training activities on certain days can should begin with plain radiography, looking minimize forces placed on the joint.11 for evidence of periosteal reaction in the region of maximal tenderness. Late findings Iliotibial band friction syndrome include fracture lines or callus formation. Iliotibial band friction syndrome produces lat- Unfortunately, radiographs do not become eral knee pain. It results from friction of the positive for at least 2 to 3 weeks; therefore, a iliotibial band gliding over the lateral femoral negative radiograph does not rule out stress condyle with repetitive knee flexion and fracture.7 If clinical suspicion for a stress frac- extension.1'10 ture is high despite negative radiographs, then Symptoms and examination. Pain often a triple-phase bone scan should be performed. begins 1 to 2 miles into a run and persists, then If available, MRI is also useful in confirming ceases once running has stopped. Downhill the clinical diagnosis. running and running on a banked tenain Treatment depends on the location of the aggravate the symptoms. fracture. Fractures of the anterior middle third Predisposing factors include calcaneal of the tibia have a risk of nonunion, delayed varies, tibia varum, and hip abductor weak- union, and displacement. Healing is pro- ness.1 On examination, tenderness is usually longed, and patients risk considerable morbid- proximal to the joint line, which distin- ity; therefore, patients with this type of frac- guishes this condition from a lateral menis- ture should be referred to an orthopedic sur- cal tear. geon.7'10 Treatment consists of icing, stretching, and strengthening the hip musculature. If the Shin splints problem persists, the patient may benefit from Medial tibial stress syndrome, or shin splints, ultrasound, ionophoresis, or corticosteroid results from of the tibial perios- For shin splints, injection. Surgery is indicated for intractable teum. It is an overuse injury in which repeti- advise stopping symptoms. tive muscle contraction results in a of the muscle insertion into the tibia. running and • LOWER LEG INJURIES IN RUNNERS Symptoms and examination. Pain occurs starting cross- with exercise and is relieved with rest. It often Most cases of lower leg pain in runners are due occurs in the novice runner or at the begin- training to medial tibial stress syndrome (shin splints), ning of the season.1 The condition is associat- activities such tibial stress fracture,13'14 or exertion compart- ed with excessive pronation of the subtalar ment syndrome. joint or midfoot. On examination, tenderness as water is elicited with palpation along the postero- running Tibial stress fracture medial tibia. Tibial stress fracture can be difficult to distin- Diagnostic tests. A bone scan may show guish clinically from medial tibial stress syn- diffuse increased uptake, whereas uptake is drome. In both conditions, patients report focally increased in tibial stress fracture. insidious onset of anterior tibial pain that Treatment consists of cessation of running occurs early in the run. In the case of shin on land until tenderness resolves. During that splints, pain may resolve during the run, time cross-training activity and water running whereas in tibial stress fracture, the pain often are permitted as long as they do not exacer- persists after the run. bate symptoms. Once symptoms resolve, the Symptoms and examination. Pain that patient may gradually resume running, but the persists after running, night pain, and pain routine should include adequate recovery peri- with ambulation should increase the index of ods and should initially be performed only on suspicion for stress fracture. On examination, soft surfaces. Use of NSAIDs and ice tenderness is usually localized. Swelling may may help resolve periosteal inflammation.

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 517 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. RUNNING INJURIES BROWNING AND DONLEY

Increasing the flexibility of the gastrocsoleus Examine for local tenderness, crepitus, or complex and the strength and endurance of nodularity, and inspect for bursal involvement the anterior musculature is also important.10 and limited dorsiflexion.10 Treatment consists of restricting activity, Exertional icing, NSAIDs, heel lifts, and a stretching and Exertional compartment syndrome in runners strengthening program. Recalcitrant cases is generally a subacute condition caused by an may respond to the use of a walking cast for 2 exercise-induced increase in the pressure to 4 weeks. Failure to respond to these nonop- within the fascial compartment due to muscle erative treatments is an indication for surgical hypertrophy and swelling.10 This leads to referral. Steroid injections increase the risk for ischemia, which results in episodic pain, tendon rupture and should be avoided.16 paresthesia, and weakness associated with exercise, which are relieved with rest.1'10 Plantar fasciitis Symptoms and examination. The patient Plantar fasciitis is the most common cause of often complains of tightness, weakness, or a inferior heel pain in runners. The plantar fas- deep ache after 15 to 20 minutes of running. cia originates from the medial calcaneal tuber- Rest generally relieves the symptoms. cle and inserts distally into the base of each Symptoms may be bilateral. The physical proximal phalanx. It supports the arch during examination may be normal. Often, the toe push-off. The condition is thought to be patient may be able to localize symptoms to a the result of repetitive microtrauma to the fas- particular compartment. cia at its origin, with an ensuing inflammato- Diagnostic tests. The diagnosis is con- ry response. Persistent overuse results in firmed by measurement of intracompartmen- chronic inflammation. Tightness of the gas- tal pressures via a catheter connected to a trocsoleus complex is associated with this con- pressure gauge. dition. Heel spurs are associated with plantar Treatment is generally conservative, con- fasciitis but do not cause it. sisting of rest, NSAIDs, and stretching. If Symptoms and examination. The classic Heel spurs are symptoms fail to respond, fasciotomy of the presentation of plantar fasciitis is inferior heel associated with involved fascial compartments provides symp- pain with the first step of the day, which tom relief. recedes with continued activity. Examination plantar fasciitis, reveals focal tenderness at the medial cal- but do not • FOOT AND ANKLE INJURIES caneal tubercle and, sometimes, at the mid- IN RUNNERS arch level. cause it Treatment. Conservative measures are Achilles tendonitis effective in 95% of patients, but the condition Achilles tendonitis is a common overuse may take up to 6 months to respond. In our injury at the insertion of the tendon or, more center, initial measures include icing, NSAIDs, often, within the mid-substance of the tendon heel pads, stretching, and strengthening. (2 to 6 cm proximal to the insertion). In some Stretching is the key to any conservative patients, the retrocalcaneal bursa may also be program and should be performed three to involved. four times a day, with attention to the Causes include repetitive impact loading, Achilles tendon and plantar . Low- excessive , tightness of impact aerobic exercise and water running

the Achilles tendon complex, 15 ancJ should be substituted for running. changes in the running routine (eg, distance, Those who do not respond may be candi- duration, or terrain).16 dates for either night splints, which place the Symptoms and examination. Patients foot in 5 degrees of dorsiflexion, or (rarely) for complain of posterior heel pain that is worse custom orthotics. Avoid corticosteroid injec- in the morning and after exercise. If the tions, as they can cause fat pad atrophy and patient complains of a sudden onset of pain or rupture.10-16 Surgery may be disability or both, then evaluate for a partial considered when symptoms persist despite 6 or complete rupture of the Achilles tendon. to 12 months of conservative treatment.

518 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. Fat pad syndrome TABLE 1 In fat pad syndrome, atrophy of the heel pad Protocol for returning to running causes central heel pain. The condition may after prolonged inactivity be due to repetitive trauma, direct trauma, or corticosteroid injection. WEEK ACTIVITY Symptoms and examination. The center of the heel pad is tender to palpation. 1 Walk 1-2 miles every day, 1 minute fast and Treatment consists of additional shoe- 1 minute at a normal pace cushioning, usually with a heel cup or pad. 2 Walk 2-3 miles every day, 1.5 minutes of fast Occasionally, a custom, orthotic is required. walking or jogging and 1.5 minute at a normal pace

Calcaneal stress fracture 3 If no pain, substitute a 10-minute jog daily in lieu of walk- ing or jogging Symptoms and examination. Calcaneal stress fracture should be ruled out when con- 4 Same as week 3, but jog 15 minutes daily in lieu of walking sidering a diagnosis of fat pad syndrome. A dis- or jogging tinguishing feature is that palpating along the 5 Jog 15 minutes 1 day, then 25 minutes the next medial and lateral borders of the calcaneus and squeezing the heel reproduce the symp- 6 Jog 20 minutes 1 day, then 30 minutes the next toms. Swelling is usually present. 7 Jog 20 minutes 1 day, 35 minutes the next Diagnostic tests. Plain radiographs usual- ly reveal the fracture. 8 Jog 20 minutes 1 day, 40 minutes the next 9 Resume normal running routine vs Morton neuroma Symptoms and examination. Meta- tarsalgia is pain on the plantar aspect of the ball of the foot. It occurs most commonly in Metatarsal stress fractures runners with a hypermobile first ray or a long Metatarsal stress fractures in runners occur second ray and is due to excessive weight most commonly in the second metatarsal Recommend transfer during push-off. It results in bone. easing back with pain at the second or third metatarsal Symptoms and examination. On exami- head, or both.17 nation, diffuse swelling and increased warmth into running, Metatarsalgia should be distinguished are frequently present. Palpation over the after injury from Morton neuroma, which occurs due to metatarsal elicits tenderness. irritation of the interdigital nerve between the Diagnostic tests. Radiographs should be metatarsal heads.1 Classically, Morton neuro- obtained. If they demonstrate a stress fracture, ma occurs in the third web space but may weight-bearing is allowed as tolerated, and the occur in the second web space. First and foot is protected in a walking-cast boot. If fourth interspace involvement is exceedingly radiographs are negative, a decision should be rare. Neuroma produces a burning or stabbing made either to treat and follow symptomati- pain that is relieved with shoe removal. cally or to obtain a bone scan to make a more Treatment. Both conditions usually definitive diagnosis. Clinically, it is often diffi- respond to the use of metatarsal pads. cult to distinguish a stress reaction from a Metatarsal pads shift some of the weight- stress fracture. bearing away from the lesser metatarsal heads Fifth metatarsal fracture vs Jones frac- and back to the first ray.17 A more general- ture. In the case of stress fracture of the fifth ized metatarsalgia may be due to a tight heel metatarsal, the clinician must be careful to dif- cord and the resulting restricted dorsiflexion ferentiate a stress fracture from a Jones frac- which produces clawing of the toes. Shoes ture—an acute fracture at the junction of the with a wide toe box often provide relief in diaphysis and metaphysis of the fifth the case of a neuroma. If recalcitrant, neuro- metatarsal. Whereas stress fracture of the fifth ma often responds to corticosteroid injec- metatarsal and avulsion fracture of the fifth tion.18 metatarsal base will usually heal without com-

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 JULY 2000 519 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission. RUNNING INJURIES BROWNING AND DONLEY

plication, Jones fracture has a propensity for the weeks of activity missed.11 The following nonunion or delayed union, and referral to an guide is useful when recommending return to orthopedic surgeon is recommended. activity: • Less than 1 week missed due to injury: & RESUMING RUNNING AFTER INJURY: no modification of the training routine is WHAT TO RECOMMEND TO PATIENTS needed • 1 to 2 weeks of running missed: reduce For patients who wish to return to running the routine by 25% for the first week of return, after an injury, especially an overuse injury, then resume appropriate routine recommend a graded return to activity with • 2 to 3 weeks of running missed: reduce appropriate recovery periods. Easy days or rest the routine by 50% for the first week of return, days should be incorporated in the workout by 25% for the second week, then resume schedule. This allows healing tissue to gradu- appropriate routine ally adapt to increased stress. • 4 weeks or more of running missed: follow Return to running after injury depends on the 9-week protocol outlined in TABLE 1. •

• REFERENCES 21:49-72. 1. Mattalino AJ, Deese JM, Campbell ED. Office evalua- 11. James SL. Running injuries of the knee. AAOS tion and treatment of lower extremity injuries in the Instructional Course Lectures 1998; 47:407-417. runner. Clin Sports Med 1989; 8:461-475. 12. Dye SF, Staubli HU, Biedert RM, Vaupel GL. The mosaic 2. Cook SD, Harding AF, Thomas KA, Morgan EL, of pathophysiology causing patellofemoral pain: thera- Schnurpfiel KM, Haddad RJ. Trabecular peutic implications. Operative Techniques in Sports and menstrual function in women runners. Am J Sports Medicine 1999; 7:46-54. Med 1987;15:503-507. 13. Matheson GO, Clement DB, McKenzie DC, Taunton JE, 3. Novacheck TF. Running injuries: a biomechanical Lloyd-Smith DR, Madntyre JG. Stress fractures in ath- approach. Instructional Course Lectures 1998; letes: a study of 320 cases. Am J Sports Med 1987; 47:397-406. 15:46-58. 4. Neely FG. Biomechanical risk factors for exercise-relat- 14. Lutter LD. Hindfoot problems. AAOS Instructional ed lower limb injuries. Sport Med 1998; 26:395-413. Course Lectures 1993; 42:195-200. 5. Thordarson DB. Running biomechanics. Clin Sports Med 15. Teitz CC, Garrett WE, Miniaci A, et al. Tendon problems 1997; 16:239-247. in athletic individuals. AAOS Instructional Course 6. Pavlov H, Nelson TL, Warren RF, Torg JS, Burstein AH. Lectures 1997; 46:569-582. Stress fractures of the pubic ramus: a report of 12 16. Jones DC. Achillestendon problems in runners. AAOS cases. J Bone Joint Surg Am 1982; 64:1020-1025. Instructional Course Lectures 1998; 47:419-427. 7. Maitra RS, Johnson DL. Stress fractures: clinical history 17. Dee R. Miscellaneous disorders of the foot. In: Dee R, and physical examination. Clin Sports Med 1997; Mango E, Hurst LC, editors. Principles of Orthopedic 16:259-274. Practice. New York: McGraw-Hill, 1989; 1445-1446. 8. Johansson C, Ekenman I, Tornkvist H, et al. Stress frac- 18. Lillich JS, Baxter DE. Common forefoot problems in tures of the femoral neck in athletes. Am J Sports Med runners. Foot Ankle 1986;7:145-151. 1990; 18:524-528. 9. Egol KA, Koval KJ, Kummer F, Frankel VH. Stress frac- ADDRESS: Kara H. Browning, MD, Department of tures of the femoral neck. Clin Orthop 1990; 348:72-78. Orthopaedic Surgery, EU-10, The Cleveland Clinic Foundation, 10. Fredericson M. Common injuries in runners: diagnosis, 99 North Line Circle #100, Euclid, OH 44119, e-mail rehabilitation, and prevention. Sports Med 1996; [email protected]

We Welcome Your Letters

WE ENCOURAGE YOU TO WRITE, MAILING ADDRESS Please be sure to include your full address, either to respond to an article published in Letters to the Editor phone number, fax number, and e-mail the Journal or to address a clinical issue of Cleveland Clinic Journal of Medicine address. Please write concisely, as space is importance to you. You may submit 9500 Euclid Ave., NA32 limited. Letters may be edited for style and Cleveland, OH 44195 letters by mail, fax, or e-mail. length. We cannot return materials sent. FAX Submission of a letter constitutes permission 216.444.9385 for the Cleveland Clinic Journal of Medicine E-MAIL [email protected] to publish it in various editions and forms.

CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 67 • NUMBER 7 Downloaded from www.ccjm.org on October 2, 2021. For personal use only. All other uses require permission.