sign in sign up
<<
Home , Achilles bursitis, Enthesopathy, Iliotibial band syndrome, Running injuries

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 and tendinopathy as they pertain to Achilles injuries. Part 1 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 as repetitive stress injuries of bone. literature, and treatment 7) Describe an outline of treat - of these conditions. ment recommendations for Achilles tendonitis, plantar , iliotibial band syndrome, patellofemoral pain BY STEPHEN PRIBUT, DPM syndrome, medial tibial stress and stress reactions of bone.

Welcome to Podiatry Management’s CME Instructional program. Our journal has been approved as a sponsor of Contin - uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $22.00 per topic) or 2) per year, for the special rate of $169 (you save $51). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. You can also take this and other exams on the Internet at www.podiatrym.com/cme. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 198 . Other than those en - tities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be ac - ceptable by any state licensing agency, hospital, managed care organization or other entity. PM will, however, use its best ef - forts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (pg. 198 ).— Editor

Introduction: Where Do We Come evolution, our scientific understand - logical phenomena and mechanobiol - From and Where Are We Going? ing also evolves. The future of the sci - ogy. Today we will take a straightfor - We’ve previously looked to the ence of will include ward look at the current state of the future in articles such as “All The items we’ve so far heard little of. Be - most frequently encountered running Small Things” 1a and examined diffi - sides genomics, we will hear more of injuries. cult problems in “Challenging Run - systems biology, stochastic phenome - Keep in mind what George Box ning Injuries”. 1b As we are products of na, Markov decision processes in bio - Continued on page 188 www.podiatrym.com APRIL/MAY 2013 | PODIATRY MANAGEMENT | 187 n ng io SPORTS PODIATRY ui at in c t du on E C al ic ed M said: “All models are wrong, but pressure, obesity, prevention of colon for a physician who is a participant some are useful.’’ You may couple cancer, and a variety of other mea - and shares their passion for running. that with the following words of wis - sures of health. 1,2 While football coaches are not usu - dom, a paraphrase of Nobel Laureate ally chosen for their ability to catch James Black: “Our models are not What Makes Runners Different or throw passes, running docs are merely pathetic descriptions of na - Runners have made their athletic frequently sought out if they are ture; they are accurate descriptions of activity an integral part of their lives. knowledgeable and also runners our pathetic thinking about nature.” Runners have begun running and themselves. Long distance running is a continue their sport for a variety of uniquely human undertaking. No reasons. Runners often participate in Physical Aspects other primate runs long distances. charity runs and dedicate their run to Most runners are physically fit, Considering mammals in general, causes or people that are close to with the exception of those who are some cover shorter distances at a them. They do not do well when recent converts to the sport. The faster speed, but only a select few are their sport is interrupted by bad ranks of marathoners continue to able to maintain a rapid pace over a long distance. The development of bipedal locomotion and an upright posture has resulted in structural and In looking at the functional differences in our muscu - biomechanics of running, it is important to remember loskeletal system and in the biome - chanical function of our locomotor that running is a one-legged sport. systems. It is thought that running may have been a significant evolu - tionary adaptation permitting easier weather, work, or even worse, an in - swell. Chorley, et al. studied runners survival by virtue of primitive ho - jury. Many times runners have inte - joining a 25-week marathon training minids’ enhanced ability to escape grated their exercise into a diet and program and found that 52% had from predators and to catch prey. weight loss program. When the run - never run a marathon before and Running is a vitally important ner is forced to stop exercise their 16% had been sedentary in the three part of the lives of many people. It is body image suffers. months prior to starting training. 3 Pre - not only a sport, an integral segment vious injuries were reported by 38% of the runners’ lives that is often car - Emotional Aspects of runners and 35% of those injuries ried out with near religious fervor. Most runners are highly motivat - were still symptomatic at the incep - Running yields health benefits rang - ed. They suffer physically and emo - tion of the training program. Desire ing from those which impact our psy - tionally when their exercise is inter - may oftentimes be greater than readi - chological well being to our physical rupted. Exercise withdrawal can have ness. No longer do the new runners health. Running has been found to a large impact on mental health and slowly work up to a marathon by run - have a positive impact on depression, may result in insomnia or depression. ning for six months to a year before cardiovascular health, muscular fit - Runners have high expectations that starting marathon training. ness, osteoporosis, diabetes, blood treatment of their injuries will be In looking at the biomechanics of speedy and have excel - running, it is important to remember lent results. Most runners that running is a one-legged sport. do not want to be told Unlike the walking gait, the runner is Abbreviations not to run! In fact, the only on one foot and leg at a time, advice most often given and never on two. Significantly higher MPFL medial patellofemoral by other runners is that forces are encountered while running. VMO vastus medialis obliquus “if a doctor tells you not The foot gear used for distance run - to run, the first thing to ning is designed for straight ahead PFPS patellofemoral pain syndrome do is to run out of their motion and is not suited for signifi - ITB iliotibial band office”. The concepts of cant side-to-side motion or sudden ITBS iliotibial band syndrome relative rest, cross-train - changes in direction. ing, and alternative forms MRI magnetic resonance imaging of exercise must be care - Risk Factors, Studies on Injury RSI repetitive stress injury fully explained to the Prevention runner. Clearly spell out After many years of study we still MTSS medial tibial stress syndrome the modifications to can not accurately predict what fac - VL vastus lateralis training that must be tors are responsible for running in - BMU bone multicellular unit made to assist in recov - juries. 4 While many have conjectured ery from injury. that shoe selection plays a role in pre - Runners often look Continued on page 189

188 | APRIL/MAY 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 dicting injury, the use of motion con - often linked to these over-training in - tar fasciitis. Is the iliotibial band trol shoes based on foot type was as - juries. These include “too much, too syndrome a problem of friction or sociated with an increased incidence soon, too fast, too often, with too lit - something else? Is the Vastus medi - of injury. The minimalist shoe move - tle rest.” alis the muscle that we need to have ment has not backed up their claims A risk factor that is omitted from the patient strengthen to improve of lowering injury rates with any hard most evaluations of running injuries quadriceps function and treat patello- data. Clinical observations seem to in - dicate that there is a change in injury pattern among minimalist shoe wear - The stress loads of exercise must be ers. Clinically those changing to mini - malist shoes and forefoot strike often gradually increased. These loads should not outpace the present with forefoot stress fractures or calf and pain. Run - body’s physical ability to adapt to the new loads. ners who would like to use minimal - ist shoes should follow the consensus of advice which is to carefully and is injury from concomitant training. femoral pain syndrome? We’ll consid - slowly transition or integrate mini - Plyometric exercises often lead to in - er these problems below. malist shoe use into their training jury. Strength training, which is often program.. supplemental and helpful, can occa - Top Five Running Injuries Over the years different injury sionally create an injury. These Pain (PFPS, ITBS) patterns have been seen. As shoes be - should be explored while taking the Achilles Tendon came more cushioned, we saw an in - patient’s history. Stress Fractures crease in Achilles and calf injuries The stress loads of exercise must Medial Tibial Stress Syndrome created by the eccentric forces occur - be gradually increased. These loads ring during heel and midfoot strike. should not outpace the body’s physi - We did see a decrease in peripatellar cal ability to adapt to the new loads. : Patellofemoral Pain pain while also seeing an increase in While some studies have not been Syndrome (PFPS) and ITB iliotibial band syndrome. As the man - sufficiently designed to discern run - Syndrome ufacturers make shoes lighter and in - ning-related injuries per hours run Called by a number of different corporate a lower heel to forefoot (RRI/1000 hours), other authors have terms over the years, patellofemoral drop, we should expect to see other posited the significance of the gradual pain is one of the top five running in - changes in injury trends. build-up although not successfully juries impacting up to 2.5 million run - A general agreement exists that demonstrated it in an epidemiological ners in the United States. Chondroma - most running injuries are injuries of study. 7 lacia patella, runner’s knee, and ante - overuse. 3-6 A detailed history must be In the rush for fitness, many are rior knee pain have all been applied taken and all aspects of a patient’s ex - injured. As we examine these in - to this condition. Since the site of ori - ercise program must be evaluated. juries, we’ll also note that there has gin of pain in this area includes sever - Look for changes in shoe use such as been an evolution in the conceptual - al structures, the appellation “chon - dromalacia” is too limiting. Therefore, the nonspecific term patellofemoral pain syndrome (PFPS) is preferred by A general agreement exists most authors. Pain here is thought to that most running injuries are injuries of overuse. 3-6 arise from any or all of the following structures: the subchondral bone, me - A detailed history must be taken dial and lateral retinaculae, infrapatel - lar fat pad and the anterior synovium. and all aspects of a patient’s exercise program Patellofemoral pain syndrome has must be evaluated. been reported to affect up to 30% of all runners. While many features of this very common malady remain to be detailed, a number of risk factors a new shoe model, a different shoe ization of many of these injuries. This have been cited over the years. The brand or old shoes that have become evolution has occurred slowly and in complex relationship of anatomical excessively worn. These changes may the face of imperfect knowledge. The alignment of the limb, patellar shape, be factors in aggravating or creating concept of tendinopathy, as the ap - presence of patella alta, and even the an injury. Besides these changes in propriate term for tendon pathology, functional aspects of the peripatellar running shoes, a change in the train - is an evolution of thought as is the retinaculum 8 have an impact on both ing program may have triggered the conceptual and terminology changes the forces occurring within this sys - problem. The “terrible too’s” are suggested for problems such as plan - Continued on page 190 www.podiatrym.com APRIL/MAY 2013 | PODIATRY MANAGEMENT | 189 n ng io SPORTS PODIATRY ui at in c t du RUNNING INJURIES on E C al ic ed M tem and the development and resolution of symptoms of this con - dition. A number of risk factors have TABLE 1 been thought to contribute to PFPS. They are detailed in Table 1. Risk Factors

Changing Concepts in PFPS • Increased Q Angle We need to keep in mind the myriad factors that come into play • Weak or ineffective Vastus Medialis (VMO) with this disorder. The stability of • Patellar Dysplasia (e.g., small medial pole of patella) the patellofemoral occurs via the interplay of structures, • Trochlear Dysplasia (congenital flattening of the lateral bone and joint surfaces, and overall femoral condyle) lower extremity biomechanics. 9 • Patella Alta (Ward et. al. JBJS 2007 Patella Alta: Association with Clearly more than excessive prona - Patellofemoral Alignment….) tion of the subtalar joint and a weak vastus medialis muscle contribute to • of Patella this problem. • Senavongse and Amis view the stabilizers of the patellofemoral • /Valgum complex as 1) active stabilizers—the • Female gender (possibly multifactoral, wider , higher Q angle, etc.) quadriceps muscles, 2) passive sta - • Malalignment of Extensor Mechanism bilizers—the retinaculum and liga - mentous structures, and 3) static • Abnormal knee joint moments 9 stabilizers—the joint surfaces. • Abnormal pronation of the foot Structures providing medial stability to the patella include the Vastus Me - • Other Lower Extremity Malalignment dialis Oblique (VMO), medial • Weak Abductors patellofemoral ligament and, to a small degree, the medial retinacu - • Increased Hip Adduction lum. 8 The patella itself is found to • Canted Surface have the lowest amount of medial stability at 20 degrees of flexion. 9 • Overtraining This is only part of the story but gives a larger picture than we usual - ly consider. extension of the knee. such as an ipsilateral lean. Quadriceps weakness is most Hip abductor weakness is associ - Abnormal pronation of the subta - often addressed in rehabilitative exer - ated with PFPS and should be ad - lar joint was first mentioned as a con - cises. While the VMO is often men - dressed in crafting a rehabilitation tributing factor to this condition in tioned as the weak link within the program. 12,13 Cichanowski noted sig - early lectures and books of George quadriceps, the VMO cannot be di - nificant differences in hip abductor Sheehan, M.D. 14 More recent research rectly and independently strength - and external rotator strength be - has confirmed Sheehan’s early feel - ings on this and reaffirmed his sug - gestion that foot orthoses were likely to be effective. 15 The only method that has emphasized the VMO The pain of PFPS appears to be over the Vastus Lateralis (VL) has been with the use caused, in part, by overload of the richly-innervated subchondral bone, of biofeedback. the extensor retinaculum, and the in - frapatellar fat pad. Chondromalacia is a surgical observation, and no longer ened using most exercise programs. tween limbs suffering from PFPS and a term applied diagnostically to this The only method that has emphasized the normal limbs. Noehren et. al. in clinical condition. the VMO over the Vastus Lateralis a prospective study of 400 female (VL) has been with the use of runners, found an increase in the Treatment of PFPS (Table 2) biofeedback. While the VMO 10,11 is hip adduction angle in those who Treatment for this condition in - known to be the primary muscular developed PFPS. 13a The study also cludes a decrease in running via rela - stabilizer of the knee, it functions noted this may occur in conjunction tive or absolute rest. NSAIDs can be throughout the range of flexion and with compensatory trunk mechanics Continued on page 191

190 | APRIL/MAY 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 used to reduce pain. It is important to should be gradual with incremental speed work. We have already strengthen the quadriceps by a care - increases in at first distance, and later noted that running is a one-legged fully instituted program. Straight leg speed work. exercise. Another important factor to lifts result in the least amount of be aware of is that with foot strike, force occurring at the patello-femoral Other Considerations the major muscle activity in the limb joint while strengthening the quadri - Patellar tendinopathy is often is to effect a braking action. The ceps. Core body exercises are recom - found alone or in conjunction with quadriceps is working after contact to mended including hip abductor exer - cises and gluteal strengthening exer - cises which may consist of bridges Another important factor to be aware of and single leg bridges. Gentle ham - string and calf stretches are also often is that with foot strike, the major muscle activity in the recommended. Lower extremity biomechanics limb is to effect a braking action. and foot structure should be assessed. Recommendations for proper shoes, and orthotics, if deemed necessary, PFPS. Patellar tendinopathy many prevent the knee from bending too should be made. Orthotics have been years ago was called “jumper’s rapidly. This creates eccentric forces found to be helpful in the treatment knee”. In runners it may be related to within the tendon. At the same time, of PFPS. 16 Resumption of running hill running, plyometric exercises or the calf muscle is firing to slow the forward motion of the , especial - ly in heel and midfoot contact gait, TABLE 2 while the gluteal muscles are firing to slow the forward motion of the Outline of Therapy for PFPS . The larger gluteal muscles have been hypothesized to come into play more with faster running and Relative or Absolute Rest speed work. Gluteal muscle activity Pain reduction with medication (NSAIDs) is clearly evident in kicking a soccer ball as the forward movement of the For 8-12 Weeks the following exercises: leg is braked. Strengthening the Therapeutic Exercise Program Strengthening the Quadriceps gluteal muscles is often used for bas - Straight leg lifts—Start with 3 sets of 10 reps each side, ketball players with this injury and is work up to 10 sets of 10 reps. equally helpful for runners. Combin - ing the therapy described above with an emphasis on gluteal strengthening Hip and Core Muscle Strengthening (Gluteus Medius, Maximus) is often successful in rapidly decreas - Bridges 10-15, Planks, After 3 weeks add Single Leg Bridges 8-12 ing the symptoms of patellar tendinopathy. Strengthen Calf Muscles—standing with knee straight Iliotibial Band Syndrome (ITBS) Posterior Stretching—Hamstrings and calf muscles Iliotibial band syndrome (ITBS) is found among the top injuries in re - Additional Therapy: cent studies. 3a The change in training Patellar Tendon and Peripatellar Massage and Manipulation methods and the characteristics of Taping or Bracing many of today’s long distance run - ners, including the “sudden marathoner syndrome”, is the most Upon return to running: likely cause of the dramatic increase Easy graded return. in this malady. For more than ten Avoid speed work years, it has been clear that ITBS is Avoid down hills associated with weak hip abductor Proper shoes for biomechanical needs of lower extremity muscles. The gluteus medius works Orthotics, if indicated hard to keep the level. Weak hip abductor muscles result in the re - Gradual return to speedwork cruitment of the muscles which insert Continue to be wary of downhill running into the iliotibial band itself to assist with hip abduction. This causes an Continued on page 192 www.podiatrym.com APRIL/MAY 2013 | PODIATRY MANAGEMENT | 191 n ng io SPORTS PODIATRY ui at in c t du RUNNING INJURIES on E C al ic ed M increase in tension developing within the ITB and possibly in - creased forces in both the tissue of TABLE 3 the ITB and the adjacent fatty tissue. Most of the historical literature refers Treatment Outline for ITBS to this syndrome as a “friction band syndrome” and was often mentioned as contributing to Relative or absolute rest the pain. 17 In spite of this terminolo - gy, no studies documenting inflam - Strengthening: mation within the tendon turned up Hip Abductor Muscle Strengthening—Standing hip tilts on one leg on a Medline search. The view that it to isolate hip abductors. is primarily a “friction”-based syn - drome is fading. Stretching: More recently further anatomical Side bends to stretch tight lateral structures, hip capsule and studies have suggested that pain in fibers inserting into the iliotibial band. The latissimus dorsi is also the iliotibial band area is not caused stretched with this exercise. The latissimus dorsi can alter trunk by friction. 18,19 Fairclough raises the and hip movements. question “Is the iliotibial band syn - drome really a friction syn - drome?” 18,19 He contends that the ITB Ancillary stretches —adductors and rotators of hip. is firmly attached to the femur and is not anatomically capable of mov - Advanced stretches: ing forward and backwards over the Stair dip lateral epicondyle of the femur. Re - Stair Strides cent cadaver studies and MRI stud - ies have failed to document the ex - Optional: pected evidence for friction or for a Ice primary anatomical bursa. Instead Foam roller an area of compression has been noted which seems to affect the rich - ly vascularized and thoroughly in - nervated fat below the tendon. On focus on controlling these secondary for patients throughout the stance MRI a zone of signal intensity abnor - plane movements through strength - phase of the running gait cycle. mality was found in this area and ening, stretching and neuromuscu - felt to be associated with intermit - lar re-education.” 21 Anatomical Considerations tent fat compression. 19,20 Muscular and neuromuscular fa - The iliotibial band (ITB) is a con - Tension within the iliotibial band tigue and the resulting kinematic tinuation of the tensor lata as a was cited by Noehren et. al. as a con - changes that occur during long dis - thickening of the lateral fascia of the tributing factor, with compression oc - tance running may also contribute to upper leg. A significant portion of the curring rather than friction: this and other overuse injuries. Im - inserts into the ITB. Along the course of its descent down the leg there are connections to the The ITBS seems to be linea aspera of the femur. The ITB fans out distally to insert on the later - primarily caused by overuse in the presence of al aspect of the patella, the lateral retinaculum and Gerdy’s tibial tuber - muscular imbalance. cle. Functionally the tensor fascia lata, gluteus medius and gluteus min - imus function as hip abductors. “The development of iliotibial pact shock, while more often studied, band syndrome appears to be relat - is not a factor. Instead, increased hip Diagnosis of ITBS ed to increased peak hip adduction adduction, an increase in knee flexion Iliotibial band syndrome (ITBS) is and knee internal rotation. These at heel strike, and maximum knee in - a clinical diagnosis which is made in combined motions may increase ili - ternal rotation velocity were found to the presence of lateral knee pain in otibial band , causing it to be higher at the end of a run in indi - the general region of the lateral compress against the lateral femoral viduals with ITBS. 22 Miller’s computer femoral epicondyle, with tenderness condyle. These data suggest that modeling system also indicated that and pain upon compression of this treatment interventions should tension would be greater in the ITB Continued on page 193

192 | APRIL/MAY 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 area while the knee is flexed and ex - clude hip abductor strengthening in lump-all category for tendon tended. Tenderness in adjacent struc - conjunction with lateral hip capsule pathology. This term includes tures, including the lateral collateral and soft tissue stretching. early stage tendinitis, paratendinitis, ligament of the knee and at the lateral NSAIDs or ice may be used to re - and later stage chronic tendinosis. joint line, should not be present. In duce discomfort. Foam rollers and tis - Histological studies have demonstrat - early stages, the pain might only sue-mobilizing massage have been ed that those with chronic tendon manifest itself while running or fol - recommended. Abnormal biomechan - pain do not have inflammatory lowing a run. ical functioning of the foot and leg changes in the affected tendon, but should be addressed, including limb rather degenerative changes. 23 Evolution in Conceptualization of length discrepancy, but there is no The term tendinosis is used specifi - ITBS (Summary) evidence that either motion-control cally to apply to with known The ITBS seems to be primarily caused by overuse in the presence of muscular imbalance. Weak hip ab - Tendinopathy may occur ductor muscles are the culprit. ITBS, in most cases, is not a friction syn - at the insertion of the Achilles tendon or within the drome with a “popping” of the ten - don over the femoral epicondyle. In - main body of the tendon itself. stead, there is a compression in this region that most often affects the fat tissue overlying the femoral epi - shoes or excessively cushioned shoes chronic degenerative changes. The condyle. Clinically, pain while walk - contribute to this condition or help to term tendinopathy itself does not have ing and tenderness is not always alleviate it. Table 3 outlines a treat - this connotation and is well used to found in the early stages. Tension ment program for ITBS. apply to overuse tendon pain and does develop within the band and swelling in the absence of a early stage tendinopathic changes Achilles Tendinopathy histopathological diagnosis (Maffulli, may be present, but no research has Khan, Paddu). In long-standing demonstrated this yet. Anatomy tendinopathy, at surgery, the tissue The same factors that create ITBS The Achilles tendon is the contin - demonstrates the appearance of mu - can lead to hip pain which is fre - uation of the gastrosoleus complex of coid degeneration. The tissue appears quently found in conjunction with muscles and is at the terminal aspect brown or yellow and shows disorgani - this condition. Hip pain associated of this multijoint system. The gastroc - zation, and an apparent lack of well- with weak hip muscles and ITBS can nemius begins above the knee joint, defined tightly bundled fibers. be caused by trochanteric or the soleus below. The on which Microscopic examination reveals de - generative changes and concomitant fi - brosis. 24 Ultrasound examination has Relative or absolute rest is an important component previously demonstrated neovascular - ization in the injured tissue. of the treatment plan for any of these running-related Achilles tendon disorders are often divided into three zones: 1) overuse syndromes. Noninsertional—the tendon proper (and paratenon), 2) conditions affect - ing the tendon insertion, and 3) proxi - gluteus medius insertional tendinopa - they have a direct impact include the mal—at the muscle tendon interface thy. A more serious condition, a tear knee joint, the ankle joint, and the and more structures proximal. 25,26 An of the hip labrum, occurs less often. subtalar joint. The most distal aspect outline based on Puddu, et al., and of the insertion becomes contiguous Werd is seen in Table 4. Treatment of ITBS with the . The complex Relative or absolute rest is an im - anatomy of the insertion is described Evolution of Thought in Insertional portant component of the treatment below as an enthesis organ. plan for any of these running-related Tendinopathy may occur at the overuse syndromes. Directly address - Pathology insertion of the Achilles tendon or ing the cause of the ITB syndrome, in For years, almost all tendon pain within the main body of the tendon most cases, seems to give significant was lumped into the category of ten - itself. It is possible that these two dif - clinical success. Weak hip abductor donitis. It was mistakenly believed fering areas may result from diverse muscles have been directly implicated that inflammation was the underlying predisposing factors. It has been sug - in this condition. An additional factor process causing the pain and patholo - gested that repeated stresses that are may be tendon and capsular tight - gy in what was called Achilles Ten - well within a clinical and functional ness. A treatment program should in - dinitis. Tendinopathy is now the Continued on page 194 www.podiatrym.com APRIL/MAY 2013 | PODIATRY MANAGEMENT | 193 n ng io SPORTS PODIATRY ui at in c t du RUNNING INJURIES on E C al ic ed M range may create the pathology be at higher risk for this injury. 28 is located on the opposing superior in a manner similar to the manner The insertion of the Achilles ten - tuberosity of the calcaneus and is in which bone stress reactions may don is complex. At the osteotendi - termed such since it is a modification occur. 27 The major contributing caus - nous junction of the Achilles tendon, of the periosteum. While rheumatolo - es cited include overuse, abnormal histological examination reveals ten - gists began viewing this insertion as biomechanical factors, fluoro - don, fibrocartilage and bone. There fundamentally different, the concept quinolone antibiotics and corticos - are three types of cartilage found of enthesis organ is only slowly teroid use. here: sesamoid, periosteal, and enthe - breaking ground in the discipline of At the insertion of the Achilles tendon, a variety of conditions may occur. In addition to insertional An enthesis is by definition tendinopathy of the Achilles tendon, one may find , the insertion point of a tendon, ligament, fascia Haglund’s deformity, and pre-tendi - nous bursitis. When the Haglund’s or articular capsule into a bone. deformity is symptomatic, it is usu - ally found as a triad of insertional tendinopathy of the Achilles tendon, sial fibrocartilage. The term “articular sports medicine. What has been a prominent posterosuperior cal - enthesis organ” has been applied to termed an insertional tendinopathy caneal process, and retrocalcaneal the insertion of the Achilles in view of might more correctly be called an in - bursitis. Insertional tendinopathy the complexity of its insertion (with sertional enthesopathy. can occur in the absence or presence the presence of a complex of fibrocar - An enthesis is by definition the in - of calcaneal bursitis. Numerous tilages, a fat pad, and bursae). 29 The sertion point of a tendon, ligament, studies indicate that insertional sesamoidal fibrocartilage is located at fascia or articular capsule into a bone. tendinopathy occurs in up to 5%— the deeper portion of the tendon and This area is susceptible to drug-in - 20% of Achilles tendon overuse in - is termed such since it is within the duced enthesopathies by fluoro - juries. 28 Older individuals appear to tendon. The periosteal fibrocartilage quinolone antibiotics (which may also affect the tendon prior to its inser - tion). In the case of the Achilles com - TABLE 4 plex, the combination of tendon, fi - brocartilage, fat pads, and bursa may Classification of Injuries to the be affected at any of those areas, or in multiple tissue types, which alters Achilles Tendon and function and forces. 30 Fibrocartilage functions to resist Surrounding Structures shear and strains at the enthesis. This new conceptualization has great and Zone 1: Non-insertional Achilles Injuries significant future implications for un - Achilles paratendinopathy derstanding of forces, function, and Achilles tendinopathy treatment of Achilles tendon inser - Achilles tendinosis tional disorders. Bone spurs which form at this lo - cation have been noted to not be within the substance of the tendon it - Zone 2: Insertional Achilles Injuries self. The relationship of the “spurs” Achilles insertional tendinopathy here to the fibrocartilage remains to Haglund’s Triad be detailed. There are several addi - Achilles insertional calific tendinopathy tional conditions to consider near the Retrocalcaneal bursitis insertion of the Achilles tendon in ad - Pre-Achilles tendon bursitis dition to insertional Achilles Avulsion fracture of calcaneus tendinopathy and enthesopathy. These conditions include retrocal - Zone 3: caneal bursitis alone and Haglund’s disease which consists of a painful Partial tears/tears of muscle-tendinous junction retrocalcaneal bursa in conjunction Strain of medial head of gastrocnemius muscle with a prominent postero-superior Plantaris strain/rupture calcaneal process. Haglund’s deformi - ty itself is often asymptomatic. In the Continued on page 195

194 | APRIL/MAY 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 differential diagnosis, be certain longer thought to be of to consider Achilles tendinopathy assistance. caused by inflammatory TABLE 5 Cross friction massage and . ice application are often used. In Achilles enthesopathy or Differential Diagnosis The modalities of ultrasound and insertional Achilles tendinopa - high voltage galvanic stimulation thy, pain is present at the back of Insertional may also be helpful. Heel lifts of the heel. The pain is aggravat - Enthesopathy and possible custom functional ed by running uphill, and by pro - foot orthotics may also assist in longed walking, standing, or run - reducing mechanical strain. ning. Table 5 offers possible dif - Seronegative After the pain is reduced, a ferential diagnoses of insertional Gout gentle and gradual return to ac - enthesopathy of the Achilles ten - Avulsion injury tivity and then speed is helpful. don. Haglund’s disease Avoiding hills or inclined tread - Sever’s disease (found in adolescents) mills is advised. Excessively Non-Insertional Achilles Retrocalcaneal bursitis cushioned shoes, which will in - Tendinopathy Systemic steroid induced injury crease the eccentric forces within The Achilles tendon is most Fluoroquinolone tendinopathy the tendon, should be avoided. often affected in non-insertional Familial hyperlipidemia Alfredson has proposed the tendinopathy at a location 2 to 6 use of eccentric stretching and Sarcoidosis cm. proximal to its insertion into strengthening with heavy loads, the calcaneus. The paratenon Diffuse idiopathic skeletal hyperostosis which when performed as de - substitutes for a true gliding syn - scribed, is meant to cause ovial sheath. It is comprised of pain. 31,32 Similar approaches have fatty areolar tissue surrounding the less no alternative is available”. been suggested for several other Achilles tendon and is organized into Training should be reduced in vol - , including patellar a mesotenon. Werd has pointed out a ume, intensity, and duration during tendinopathy. Two review articles ex - clinical manner of distinguishing the use of fluoroquinolones with care - amining eccentric strengthening as tendinopathy from paratendinopa - ful monitoring and an easy return to treatment for a number of tendons thy. 25 Upon palpation of the painful full activity during the month follow - were recently published. 33 The au - area, if the foot is dorsiflexed and ing treatment completion. 25a thors thought, in general, that the evi - plantarflexed and it is noted that the dence was weak and underpowered. area of maximal tenderness does not Additional Calf and Posterior It is important to note that Alfredson move, the presumption is that the site Calcaneal Injuries has recommended that eccentric of tenderness is within the paratenon Injuries to runners are also noted stretching should not be used to treat itself, which is firmly attached to the at the myotendinous junction, within insertional Achilles tendinopathy. 32a surrounding tissues and does not move. If the tenderness shifts with dorsiflexion and plantarflexion, the For severe, chronic, tenderness is deemed to be within the tendinous tissue. and unremitting tendinosis, surgery remains Fluoroquinolone use is associated with non-insertional Achilles tendon an option. injuries. The risk is increased with a concomitant use of oral corticos - teroids, increasing age, magnesium the calf muscle itself, and to the The current literature was de - deficiency, and HLA B27 associated plantaris. scribed as having a “dearth of high disease. The mechanism of injury has quality research in support of the clin - not been definitively described. Con - Approach to Treatment ical effectiveness of EE (eccentric ex - tributing factors may include the Conservative treatment is directed ercise) over other treatments in the chelation of Mg2+ by the Fluoro - to decreasing strain on the tendon management of tendinopathies.” 33 quinolone which may affect the trans - and allowing the tissue to repair it - Kingma, et al. agreed, that while the membrane integrin proteins. A reduc - self. Relative rest, absolute rest or the technique appeared promising “large tion in collagen type I, elastin, fi - use of a pneumatic walking boot may methodologically sound studies ….are bronectin, and Beta1 Integrin which be required. NSAIDs are often used, warranted.” 34 mimics Magnesium deficiency has and offer a decrease in symptoms and For severe, chronic, and unremit - been found in dogs given fluoro - a more normal gait and motion pat - ting tendinosis, surgery remains an quinolones. Athletes should avoid “all tern through pain reduction, although option. The described surgical proce - use of fluoroquinolone antibiotics un - their anti-inflammatory effects are no Continued on page 196 www.podiatrym.com APRIL/MAY 2013 | PODIATRY MANAGEMENT | 195 n ng io SPORTS PODIATRY ui at in c t du RUNNING INJURIES on E C al ic ed M dures include stripping of the cent Concepts in patellofemoral instability. Injuries. J Am Podiatr Med Assoc, 2007. paratenon, linear tenotomies, and Curr Opin Orthop, 2007. 18: p. 153-160. 97(1): p. 37-46. excision of non-viable tissue. 28,35 12 Cichanowski, H., et al., Hip Strength 25a Hall, M., et. al. Musculoskeletal Treatment for Achilles tendinopa - in Collegiate Female Athletes with Complications of Fluoroqunolones: Guide - thy is outlined in Table 5. PM Patellofemoral Pain. Med Sci Sports Exerc, lines and Precautions for Usage in the Ath - 2007. 39(8): p. 1227-1232. letic Population. American Academy of 13 Tyler, T.F., et al., The role of hip Physical Medicine and Rehabilitation. Vol. References muscle function in the treatment of 3, 132-142, February 2011 1a Pribut, S., Overuse Running Injuries patellofemoral pain syndrome. Am J 26 Puddu, G., E. Ippolito, and F. Posta - of Bone and Tendon: All The Small Sports Med, 2006. 34(4): p. 630-6. chini, A classification of Achilles Tendon Things. Podiatry Management Magazine. 13a Noehren, B., Hamill, J., and Davis, Disease. Am J Sports Med, 1976. 4. November, 2010. I., Prospective Evidence for a Hip Etiology 27 Rees, J., Wilson, AM, Wolman, RL, 1b Pribut, S.,Challenging Running In - in Patellofemoral Pain. Med Sci Sports Current concepts in the management of juries. Podiatry Management Magazine. Exerc, 2013. Publish ahead of Print DOI: tendon disorders. Rheumatology, 2006. 45: January, 2010. 10.1249/Mss.0b013e31828249d2 p. 508-521. 1 Presiden - 14 Sheehan, G., Dr. Sheehan on Run - 28 Maffulli, N. and L.C. Almekinders, t’s_Council_on_Physical_Fitness. Physical ning. 1975, Mountain View: World Publi - The Achilles Tendon. 2007, London: Fitness Facts/Healthy People 2010. 2007 cations. Springer-Verlog. (cited 2008 1/08/2008). 15 Powers, C.M., et al., Comparison of 29 Benjamin, M., et al., The “enthesis 2 Willems, T.M., et al., Gait-related foot pronation and lower extremity rota - organ” concept: Why entesopathies may risk factors for exercise-related lower-leg tion in persons with and without not present as focal insertional disorders. pain during shod running. Med Sci Sports patellofemoral pain. Foot Ankle Int, 2002. Arthritis Rheum, 2004. 50(10): p. 3306- Exerc, 2007. 39(2): p. 330-9. 23: p. 634-640. 3313. 3 Chorley, J.N., et al., Baseline injury 16 Saxena, A. and J. Haddad, The Ef - 30 Slobodin, G., et al., Varied Presenta - risk factors for runners starting a fect of Foot Orthoses on Patellofemoral tions of Enthesopathy. Semin Arthritis marathon training program. Clin J Sport Pain Syndrome. J Am Podiatr Med Assoc, Rheum, 2007. 37(2): p. 119-126. Med, 2002. 12(1): p. 18-23. 2003. 93(4): p. 264-271. 31 Alfredson, H., et al., Heavy-load ec - 3a Lopes, A.D., et. al., What are the 17 Fredericson, M. and C. Wolf, Iliotib - centric calf muscle training for the treat - main running-related musculoskeletal in - ial band syndrome in runners: innovations ment of chronic Achilles tendinosis. Am J juries? A systematic review. Sports Med in treatment. Sports Med, 2005. 35(5): p. Sports Med, 1998. 26(3): p. 360-6. 2012; 42 (10): 891-905 451-9. 32 Alfredson, H. and J. Cook, A treat - 4 van Gent, R.N., et al., Incidence and 18 Fairclough, J., et al., Is iliotibial ment algorithm for managing Achilles determinants of lower extremity running band syndrome really a friction syndrome? tendinopathy: new treatment options. Br J injuries in long distance runners: a system - Journal of Science and Medicine in Sport, Sports Med, 2007. 41(4): p. 211-216. atic review. Br J Sports Med, 2007. 41(8): 2007. 10(2): p. 74-76. 32a Ohberg L, Alfredson H. Sclerosing p. 469-80; discussion 480. 19 Fairclough, J., et al., The functional therapy in chronic Achilles tendon inser - 5 Hreljac, A., Etiology, prevention, and anatomy of the iliotibial band during flex - tional pain—results of a pilot study. Knee early intervention of overuse injuries in ion and extension of the knee: implica - Surg Sports Traumatol Arthrosc 2003; runners: a biomechanical perspective. tions for understanding iliotibial band syn - 11(5): 339-43. Phys Med Rehabil Clin N Am, 2005. 16(3): drome. Journal of Anatomy, 2006. 208(3): 33 Woodley, B.L., R.J. Newsham-West, p. 651-67, vi. p. 309-316. and D.B. Baxter, Chronic tendinopathy: ef - 6 Kelsey, J.L., et al., Risk factors for 20 Muhle, C., et al., Iliotibial Band Fric - fectiveness of eccentric exercise. Br J among young female cross- tion Syndrome: MR Imaging Findings in 16 Sports Med, 2007. 41: p. 188-199. country runners. Med Sci Sports Exerc, Patients and MR Arthrographic Study of 34 Kingma, J.J., et al., Eccentric over - 2007. 39(9): p. 1457-63. Six Cadaveric . Radiology, 1999. load training in patients with chronic 7 Buist, I., et al., No Effect of a Graded 212(1): p. 103-110. Achilles tendinopathy. Br J Sports Med, Training Program on the Number of Run - 21 Noehren, B., I. Davis, and J. Hamill, 2007. 41:e3(6). ning-Related Injuries in Novice Runners: A ASB Clinical Biomechanics Award Winner 35 Saxena, A., Results of chronic Randomized Controlled Trial. Am J Sports 2006. Prospective study of the biomechani - Achilles tendinopathy surgery on elite and Med, 2008. 36(1): p. 33-39. cal factors associated with iliotibial band nonelite track athletes. Foot Ankle Int, 8 Powers, C.M., et al., Role of Peri - syndrome. Clin Biomech (Bristol, Avon), 2003. 24. patellar Retinaculum in Transmission of 2007. 22(9): p. 951-956. Forces Within the Extensor Mechanism. J 22 Miller, R.H., et al., Lower extremity Bone Joint Surg Am, 2006. 88(9): p. 2042- mechanics of iliotibial band syndrome dur - Dr. Pribut is a Clinical 2048. ing an exhaustive run. Gait Posture, 2007. Assistant Professor of 9 Senavongse, W. and A.A. Amis, The 26(3): p. 407-13. Surgery at George effects of articular, retinacular, or muscu - 23 Movin, T., et al., Tendon pathology Washington University lar deficiencies on patellofemoral joint sta - in long-standing achillodynia. Biopsy find - Medical School. He bility. J Bone Joint Surg Br, 2005. 87-B(4): ings in 40 patients. Acta Orthop Scand, serves on the Runner’s p. 577-582. 1997. 68(2): p. 170-5. World Board of Advi - 10 Goh, J.C., P.Y. Lee, and K. Bose, A 24 Khan, K.M., et al., Histopathology of sors. He is a past presi - Cadaver Study of the Function of the common tendinopathies. Update and im - dent of the American Oblique Part of Vastus Medialis. J Bone plications Sports Med, 1999. 27: p. 393- Academy of Podiatric Joint Surg Br, 1995. 77-B: p. 225-231. 408. Sports Medicine. Dr. Pribut is in private practice 11 Merchant, N.D. and C. Bennett, Re - 25 Werd, M., Achilles Tendon Sports in Washington, DC.

196 | APRIL/MAY 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 199 .

1) Running gait demonstrates what is appropriately termed: 12) The histological findings of which of the following features: A) Runner’s Knee tendinosis include: A) Two feet are in contact with B) Patellofemoral pain A) myxoid degeneration the ground 25% of the stance syndrome B) parakeratosis phase C) C) inflammatory exudates B) Two feet are in contact with D) terrible triad D) copius lymphocytes the ground 75% of the stance phase 7) Evidence in studies has indicat - 13) Fluoroquinolone use has C) The forces of running are ed that a large contributing factor been associated with: less than the forces of walking. to iliotibial band syndrome is: A) Achilles tendinopathy D) Two feet are never in con - A) weak hip abductor muscles and enthesopathy tact with the ground at the B) over pronation of the foot B) Peri-patellar pain same time. C) high arches sydnrome D) low blood levels of Vitamin D C) Stress fractures 2) A viable approach to ITB D) Osteopenia Syndrome would not include: 8) The pain of iliotibial band syn - A) Strengthening hip drome is most often experienced 14) Minimalist shoe gear has abductors in the region of the: been clinically associated with: B) Decreasing running and A) anterior knee A) Change to a “paleo” diet “relative rest” B) posterior aspect of the knee B) ITB sydnrome C) Soft shock absorbing shoes C) medial aspect of the knee C) Achilles tendinopathy D) Side bends to stretch tight D) lateral aspect of the knee. and forefoot stress fractures lateral structures D) Osteoarthritis of the hip 9) The most frequently occurring and knee 3) In reference to the impact on Achilles tendon injuries in run - the patellofemoral complex, the ners are best termed 15) Hakim Alfredson, the vastus medialis oblique is: A) Achilles tendonitis author of several studies A) a static stabilizer B) Achilles heel on eccentric stretching in the B) a dynamic stabilizer C) treatment of Achilles tendinopa - C) a passive stabilizer D) Achilles tendinopathy thy, does not recommend D) a destabilizer it for: 10) All of the following types of A) Non-insertional Achilles 4) The patella has the least footgear could aggravate pain in tendinopathy of 4-6 weeks amount of medial stability at: the Achilles tendon area except: duration A) zero degrees of flexion A) zero drop, minimalist shoes B) Non-insertional Achilles B) 20 degrees of flexion and a switch to forefoot con - tendinopathy of 6-8 weeks C) 45 degrees of flexion tact running style duration D) 90 degrees of flexion. B) firm heel shoe, flexible C) Non-insertional Achilles at ball, with 1/4” heel lift tendinopathy of 10-14 weeks 5) Factors considered important to C) well-cushioned shoes duration the development of patellofemoral D) shoes with a stiff and D) Insertional Achilles pain syndrome include: hard-to-bend sole. tendinopathy A) abnormal pronation of the foot 11) The insertion of the Achilles 16) The following statement B) patella alta tendon and the plantar fascia are about patellofemoral pain C) weak hip abductor similar in that they both: disorder is false: muscles A) insert into the talus A) the preferred name D) all of the above. B) are both improved with of this condition is anterior stiff running shoes knee pain 6) Pain that develops after run - C) are improved by jumping B) pronation of the foot ning in the anterior region of a pa - jacks and running in sand has been found in studies to tient’s knee is most likely to be D) are entheses Continued on page 198 www.podiatrym.com APRIL/MAY 2013 | PODIATRY MANAGEMENT | 197 n ng io ui at in c t du on E CME EXAMINATION PM’s C al ic ed M CPME Program

be a risk factor Welcome to the innovative Continuing Education C) studies indicate weak hip abductors to be Program brought to you by Podiatry Management associated with PFPS Magazine. Our journal has been approved as a D) the subchondral bone, extensor sponsor of Continuing Medical Education by the retinaculum and infrapatellar fat pad are Council on Podiatric Medical Education. possible sources of pain in PFPS.

17) All of the following statements about the Now it’s even easier and more convenient to Achilles tendon insertion are true except: enroll in PM’s CE program! A) Fibrocartilage is found at the insertion of You can now enroll at any time during the year the Achilles tendon and submit eligible exams at any time during your B) Sesamoidal cartilage is found at the enrollment period. insertion of the Achilles tendon C) periosteal cartilage is found at the PM enrollees are entitled to submit ten exams insertion of the Achilles tendon published during their consecutive, twelve–month D) articular cartilage is found at the insertion enrollment period. Your enrollment period begins of the Achilles tendon with the month payment is received. For example, if your payment is received on September 1, 2006, 18) Surgical treatment of Achilles tendinosis your enrollment is valid through August 31, 2007. most commonly would likely include any of the following except: If you’re not enrolled, you may also submit any A) stripping of the paratenon exam(s) published in PM magazine within the past B) excision of non-viable tissue twelve months. CME articles and examination C) Gastrocnemius recession (e.g., Strayer questions from past issues of Podiatry Manage - Procedure) ment can be found on the Internet at D) linear tenotomy http://www.podiatrym.com/cme. Each lesson is 19) The most specific statement we can make approved for 1.5 hours continuing education con - about the Gastrosoleus complex and the tact hours. Please read the testing, grading and pay - Achilles tendon is that this complex is: ment instructions to decide which method of par - A) Multi-joint functioning ticipation is best for you. B) Primary function is supination of the Please call (631) 563-1604 if you have any ques - subtalar joint tions. A personal operator will be happy to assist you. C) Primary function is plantar flexion of the great toe in ballet dancers Each of the 10 lessons will count as 1.5 credits; D) associated with ITB syndrome thus a maximum of 15 CME credits may be earned 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 contributed to by all of the following except: The Podiatry Management Magazine CME A) carbohydrate loading B) overtraining program is approved by the Council on Podiatric C) shoes losing shock absorption and wearing Education in all states where credits in instructional down substantially media are accepted. This article is approved for D) starting marathon training never having 1.5 Continuing Education Contact Hours (or 0.15 run more than 20 minutes at a time CEU’s) for each examination successfully completed.

Home Study CME credits now

See answer sheet on page 199 . accepted in PCeontinnuseyd lovnapangiea

198 | APRIL/MAY 2013 | PODIATRY MANAGEMENT www.podiatrym.com £ M C e o di n ca ti l nu E in Enrollment/Testing Information du g ca ti and Answer Sheet on Note: If you are mailing your answer sheet, you must complete all rolled in the annual exam CPME program, and we receive this exam info. on the front and back of this page and mail with your credit card during your current enrollment period. If you are not enrolled, please information to: Podiatry Management , P.O. Box 490, East Islip, send $22.00 per exam, or $169 to cover all 10 exams (thus saving $51 NY 11730. over the cost of 10 individual exam fees). TESTING, GRADING AND PAYMENT INSTRUCTIONS Facsimile Grading (1) Each participant achieving a passing grade of 70% or higher To receive your CPME certificate, complete all information and fax on any examination will receive an official computer form stating the 24 hours a day to 1-631-563-1907. Your CPME certificate will be dated number of CE credits earned. This form should be safeguarded and and mailed within 48 hours. This service is available for $2.50 per exam may be used as documentation of credits earned. if you are currently enrolled in the annual 10-exam CPME program (and (2) Participants receiving a failing grade on any exam will be noti - this exam falls within your enrollment period), and can be charged to fied and permitted to take one re-examination at no extra cost. your Visa, MasterCard, or American Express. (3) All answers should be recorded on the answer form below. If you are not enrolled in the annual 10-exam CPME program, the For each question, decide which choice is the best answer, and circle fee is $22 per exam. the letter representing your choice. Phone-In Grading (4) Complete all other information on the front and back of this page. You may also complete your exam by using the toll-free service. (5) Choose one out of the 3 options for testgrading: mail-in, fax, or Call 1-800-232-4422 from 10 a.m. to 5 p.m. EST, Monday through phone. To select the type of service that best suits your needs, Friday. Your CPME certificate will be dated the same day you call and please read the following section, “Test Grading Options”. mailed within 48 hours. There is a $2.50 charge for this service if you are TEST GRADING OPTIONS currently enrolled in the annual 10-exam CPME program (and this exam Mail-In Grading falls within your enrollment period), and this fee can be charged to your To receive your CME certificate, complete all information and Visa, Mastercard, American Express, or Discover. If you are not current - mail with your credit card information to: ly enrolled, the fee is $22 per exam. When you call, please have ready: 1. Program number (Month and Year) Podiatry Management 2. The answers to the test P.O. Box 490, East Islip, NY 11730 3. Your social security number PLEASE DO NOT SEND WITH SIGNATURE REQUIRED, AS 4. Credit card information THESE WILL NOT BE ACCEPTED. In the event you require additional CPME information, please There is no charge for the mail-in service if you have already en - contact PMS, Inc., at 1-631-563-1604 .

ENROLLMENT FORM & ANSWER SHEET Please print clearly...Certificate will be issued from information below.

Name ______Soc. Sec. #______Please Print: FIRST MI LAST Address______City______State______Zip______Charge to: _____Visa _____ MasterCard _____ American Express Card #______Exp. Date______Note: Credit card is the only method of payment. Checks are no longer accepted. Signature______Soc. Sec.#______Daytime Phone______State License(s)______Is this a new address? Yes______No______

Check one: ______I am currently enrolled. (If faxing or phoning in your answer form please note that $2.50 will be charged to your credit card.) ______I am not enrolled. Enclosed is my credit card information. Please charge my credit card $22.00 for each exam submitted. (plus $2.50 for each exam if submitting by fax or phone). ______I am not enrolled and I wish to enroll for 10 courses at $169.00 (thus saving me $51 over the cost of 10 individual exam fees). I understand there will be an additional fee of $2.50 for any exam I wish to submit via fax or phone.

www.podiatrym.com Over, please APRIL/MAY 2013 | PODIATRY MANAGEMENT | 199 £ d) www.podiatrym.com nue conti ( ET E SH y trongl S n e n Se o sagree di s ati lu /13 ] [1 a 4 rie ju n t) bu I Ev # SWER AN n sagree Di ri (P & AM sso ] 1 [2 g in n n u EX Le R n t ar P o e ____ Neutral Fiv RM FO ce— ____ p ] [3 fi cati du ce practi ____ o T E Of l my a Agree y gl he NT he e: to T l t esson l ron c s thi shed i ompl t n S NT ME i ] [4 s thi on acc Medic Cir L e pful hel ANAGEME gre from a M were based was RY L RO ves ti ] [5 earned l esson l DIAT equate I or behavi EN ad objec PO e | th i CME nal w ce racti 2013 o ati p edg owl s Thi

)

n k

n 1

my

o educ i

t n i

the a

c RIL/MAY

g The ?

u on nformati i

n )

d

i AP

2 E

u esson? l |

y appl

l

n hanges

i 0 a ty i al

t c

c

i

n s thi

20 tes

l l wi qu

essons l d

o I

e

C

) es ak

M

3

m nted CME

ete mpl

re

l l wi

co

tu

prese

I

nu ______mi

to

) u

4 f

____

n i

you

____

esson l

ces see ABCD ABCD e tak to ABCD s Thi ABCD esson t i ) l ABCD ______hour ABCD 5 11. e k i l ABCD referen 12. ABCD d di 13. ABCD 14. ABCD 15. you 16. 17. ong l d l 18. urrent 19. c 20. ow wou H cs i op t hat : W st ABCD i l ABCD ABCD ABCD se . ABCD . ABCD 1 . ABCD 2 ea . ABCD 3 . ABCD 4 . Pl ABCD 5 . 6 . ______7 . 8 . 9 10