Apr08 p117-134 CME-BG · PFPS and iliotibial band syndrome. 3) Review the significance of...

minids’ enhanced ability to escapefrom predators and to catch prey.

Running is a vitally importantpart of the lives of many people. Itis not only a sport, but an integralsegment of the runners’ lives that isoften carried out with near reli-gious fervor. Running yields healthbenefits ranging from those which

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APRIL/MAY 2008 • PODIATRY MANAGEMENTwww.podiatrym.com 117

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Objectives1) Describe the features of the top

running injuries.

2) Present recent concepts on muscleimbalance and the relationship of coremuscles to clinical entities includingPFPS and iliotibial band syndrome.

3) Review the significance oftendinopathy and fasciopathy in clinicalpractice.

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

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

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

7) Describe an outline of treatmentrecommendations for Achilles ten-donitis, plantar fasciitis, iliotibial bandsyndrome, patellofemoral pain syn-drome, medial tibial stress and stressreactions of bone.

development of bipedal locomo-tion and an upright posture has re-sulted in structural and functionaldifferences in our musculoskeletalsystem and in the biomechanicalfunction of our locomotor systems.It is thought that running mayhave been a significant evolution-ary adaptation permitting easiersurvival by virtue of primitive ho-

The Top FiveRunningInjuries Seen in the Office

By Stephen Pribut, DPM

Long distance running is auniquely human undertak-ing. No other primate runs

long distances. Considering mam-mals in general, some cover shorterdistances at a faster speed, but onlya select few are able to maintain arapid pace over a long distance. The

Here’s the current evolution in thought, literature, and treatment of these conditions.

S P O R T S P O D I A T R YS P O R T S P O D I A T R Y

The Top FiveRunningInjuries Seen in the OfficeHere’s the current evolution in thought, literature, and treatment of these conditions.

Phot

odis

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docs are frequently sought out ifthey are runners.

Physical AspectsMost runners are physically fit,

with the exception of those whoare recent converts to the sport. Re-cently, the ranks of marathonershave swollen with many new run-ners. Chorley, et al. studied runnersjoining a 25-week marathon train-ing program and found that 52%had never run a marathon beforeand 16% had been sedentary in thethree months prior to starting

training.3 Previous injurieswere reported by 38% ofrunners and 35% of thoseinjuries were still symp-tomatic at the inception ofthe training program. Desiremay oftentimes be greaterthan readiness. No longerdo the new runners slowlywork up to a marathon byrunning for six months to ayear before starting mara-thon training.

In looking at the biome-chanics of running, it is im-portant to remember that

running is a one legged sport. Un-like the walking gait, the runner isonly on one foot and leg at a time,and never on two. Significantlyhigher forces are encountered whilerunning. The foot gear used for dis-tance running is designed forstraight ahead motion and is notsuited for significant side-to-sidemotion or sudden changes in direc-tion.

Risk Factors, Studies on InjuryPrevention

Accurately predicting what fac-tors are responsible for running in-juries has not been readily achiev-able in studies thus far.4 A generalagreement exists, however, thatmost running injuries are injuriesof overuse.3-6 All aspects of a patien-t’s exercise program must be evalu-ated. There may have been achange in the patient’s shoes, withthem becoming excessively worn,or the shoes may have been re-placed by an inappropriate pair. Achange in the training programmay have triggered the problem.This can occur when what has been


118 www.podiatrym.comPODIATRY MANAGEMENT • APRIL/MAY 2008

Injuries...

impact our psychological wellbeing to our physical health.

Running has been found to have apositive impact on depression, car-diovascular health, muscular fit-ness, osteoporosis, diabetes, bloodpressure, obesity, prevention ofcolon cancer, and a variety of othermeasures of health.1,2

What Makes RunnersDifferent

For those who have made thissport a vital part of their lives, itmay just be their favorite aspect ofevolution. But along with this evo-lution, runners have developedtheir own special and unique out-look towards their bodies.

Emotional AspectsRunners have high expectations

that treatment of their injurieshave both excellent results and thatthese results be quickly achieved.Most runners are highly motivatedand are not patient. Exercise with-drawal can have a large impact ontheir mental health and may resultin insomnia or depression. Mostrunners do not want to be told notto run! The concepts of relativerest, cross-training, and alternativeforms of exercise must be carefullyexplained to the runner. It is there-fore important to spell out clearlythe modifications to training thatmust be made to assist runners inrecovery from injury.

Runners often look for a physi-cian who is a participant andshares their passion for running.While football coaches are notusually chosen for their ability tocatch or throw passes, running

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TABLE 1

Risk Factors• Increased Q Angle

• Weak or ineffective Vastus Medialis (VMO)

• Patellar Dysplasia (e.g., small medial pole of patella)

• Trochlear Dysplasia (congenital flattening of the lateral femoral condyle)

• Patella Alta (Ward et. al. JBJS 2007 Patella Alta: Association with Patellofemoral Alignment….)

• Hypermobility of Patella

• Ligamentous Laxity

• Genu Varum/Valgum

• Female gender (possibly multifactoral, wider hips, higher Q angle, etc.)

• Malalignment of Extensor Mechanism

• Abnormal knee joint moments

• Abnormal pronation of the foot

• Other Lower Extremity Malaligment

• Weak Hip Abductors

• Canted Surface

• Overtraining

AbbreviationsMPFL medial patellofemoral ligamentVMO vastus medialis obliquusPFPS patellofemoral pain syndromeITB iliotibial bandITBS iliotibial band syndromeMRI magnetic resonance imagingRSI repetitive stress injuryMTSS medial tibial stress syndrome


of tendinopathy, as the appropriateterm for tendon pathology, is anevolution of thought as is the con-ceptual and terminology changessuggested for problems such asplantar fasciitis. Is the iliotibialband syndrome a problem of fric-tion or something else? Is the Vas-tus medialis the muscle that weneed to have the patient strengthento improve quadriceps functionand treat patello-femoral pain syn-drome? We’ll consider these prob-lems below.

Top Five Running InjuriesKnee Pain (PFPS, ITBS)Achilles TendonStress FracturesMedial Tibial Stress SyndromePlantar Fasciitis

Knee Pain: PatellofemoralPain Syndrome and ITBSyndrome

Called by a number of differentterms over the years, patellofemoralpain is one of the top five runninginjuries. Chondromalacia patella,runner’s knee, and anterior knee

termed the “terrible too’s” occurs.These include “too much, too soon,too fast, too often, with too littlerest.”

The stress loads of exercise mustbe gradually increased. These loadsshould not outpace the body’sphysical ability to adapt to the newloads. While some studies have notbeen sufficiently designed to dis-cern running-related injuries perhours run (RRI/1000 hours), otherauthors have posited the signifi-cance of the gradual build-up al-though not successfully demon-strated it in an epidemiologicalstudy.7

In the rush for fitness, many areinjured. This article reviews the topfive running-related injuries forwhich patients seek treatment, witha bonus injury or two. As we exam-ine these injuries, we’ll also notethat there has been an evolution inthe conceptualization of many ofthese injuries. This evolution hasoccurred slowly and in the face ofimperfect knowledge. The concept

Injuries... pain have all been ap-plied to this condition.Since the site of origin of painin this area includes severalstructures, the appellation “chon-dromalacia” is too limiting. There-fore, the nonspecific termpatellofemoral pain syndrome(PFPS) is preferred by most authors.Pain here is thought to arise fromany or all of the following struc-tures: the subchondral bone, medi-al and lateral retinaculae, infrap-atellar fat pad and the anterior syn-ovium. Patellofemoral pain syn-drome has been reported to affectup to 30% of all runners. Whilemany features of this very commonmalady remain to be detailed, anumber of risk factors have beencited over the years. The complexrelationship of anatomical align-ment of the limb, patellar shape,presence of patella alta, and eventhe functional aspects of the peri-patellar retinaculum8 have an im-pact on both the forces occurringwithin this system and the develop-ment and resolution of symptomsof this condition. A number of riskfactors have been thought to con-tribute to PFPS. They are detailed inTable 1.

Changing Concepts in PFPSWe need to keep in mind the

myriad factors that come into playwith this disorder. The stability ofthe patellofemoral joint occurs viathe interplay of soft tissue struc-tures, bone and joint surfaces, andoverall lower extremity biomechan-ics.9 Clearly more than excessivepronation of the subtalar joint anda weak vastus medialis muscle con-tribute to this problem.

Senavongse and Amis view thestabilizers of the patellofemoralcomplex as 1) active stabilizers—the quadriceps muscles, 2) passivestabilizers—the retinaculum andligamentous structures, and 3) stat-ic stabilizers—the joint surfaces.9

Structures providing medial stabili-ty to the patella include the VMO,medial patellofemoral ligamentand, to a small degree, the medialretinaculum.8 The patella itself isfound to have the lowest amountof medial stability at 20 degrees offlexion.9 This is only part of thestory but gives a larger picture than


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TABLE 2

Outline of Therapy for PFPSRelative or Absolute RestPain reduction with medication (NSAIDs)

For 8-12 Weeks the following exercises:Therapeutic Exercise Program Strengthening the Quadriceps

Straight leg lifts—Start with 3 sets of 10 reps each side, work up to10 sets of 10 reps.

Hip and Core Muscle Strengthening (Gluteus Medius, Maximus)Strengthen Calf Muscles—standing with knee straightStrengthen Gluteal Muscles—standing, knee as straight as possible.

Posterior Stretching

Additional Therapy:Patellar Tendon and Peripatellar Massage and ManipulationTaping or Bracing

Upon return to running:Easy graded return.Avoid speed workAvoid down hillsProper shoes for biomechanical needs of lower extremityOrthotics, if indicated

Gradual return to speedworkContinue to be wary of downhill running

cludes a decrease in running via rel-ative or absolute rest. NSAIDs canbe used to reduce pain. It is impor-tant to strengthen the quadricepsby a carefully instituted program.Straight leg lifts result in the leastamount of force occurring at thepatello-femoral joint whilestrengthening the quadriceps. Corebody strengthening has also beenrecommended.

Lower extremity biomechanicsand foot structureshould be as-sessed. Recom-mendations forproper shoes, andorthotics, ifdeemed neces-sary, should bemade. Orthoticshave been foundto be helpful inthe treatment ofPFPS.16 Resump-tion of runningshould be gradualwith incremental

increases in at first distance, andlater speed work.

Iliotibial Band Syndrome(ITBS)

Twenty years ago iliotibial bandsyndrome (ITBS) was an infrequentdiagnosis. More recently it has be-come a substantial cause of pain inrunners. The change in training

and thecharacteris-tics of manyof today’slong dis-tance run-ners, includ-ing the “sud-d e nmarathonersyndrome”,is the mostlikely causeof the dra-matic in-crease in thismalady. Ithas becomeclear thatITBS is asso-ciated withweak hip ab-ductor mus-cles. Weakhip abductor

muscles result in the recruitment ofthe muscles which insert into theiliotibial band to assist with hip ab-duction. This causes an increase intension developing within the ITBitself.

Keep in mind that running is aone-legged exercise and it is impor-tant to keep the pelvic bone levelthrough the work of the gluteusmedius. There is the possibility thatwhat occurs within the ITB is atendinopathy. Most of the histori-cal literature refers to this syn-drome as a “friction band syn-drome” and inflammation wasoften mentioned as contributing tothe pain.17 In spite of this terminol-ogy, no studies documenting in-flammation within the tendonturned up on a Medline search.

More recently further anatomi-cal studies have suggested that painin the iliotibial band area is notcaused by friction.18,19 Faircloughraises the question “Is the iliotibialband syndrome really a frictionsyndrome?”18,19 He contends thatthe ITB is firmly attached to thefemur and is not anatomically ca-pable of moving forward and back-wards over the lateral epicondyle ofthe femur. Recent cadaver studiesand MRI studies have failed to doc-ument the expected evidence forfriction or for a primary anatomicalbursa. Instead an area of compres-



Injuries...

we usually consider.Quadriceps weakness is most

often addressed in rehabilitativeexercises. While the VMO is oftenmentioned as the weak link withinthe quadriceps, the VMO cannot bedirectly and independentlystrengthened using most exerciseprograms. The only method thathas emphasized the VMO over theVL has been with the use ofbiofeedback. The concept that theVMO only comes into play in theend range of motion and exercisesthat emphasize motion at the endrange of extension isolate the VMOhas been found to be false. Whilethe VMO10,11 is known to be the pri-mary muscular stabilizer of theknee, it functions throughout therange of flexion and extension ofthe knee.

Hip abductor weakness has re-cently been found to be associatedwith PFPS and may be another areafor therapeutic intervention.12,13

Confirmation of this suspicion wasmade by Cichanowski, who notedsignificant differences in hip abduc-tor and external rotator strengthbetween limbs suffering from PFPSand the normal limbs.

Abnormal pronation of the sub-talar joint was first mentioned as acontributing factor to this condi-tion in early lec-tures and books ofGeorge Sheehan,M.D.14 More re-cent research hasconfirmed Shee-han’s early feel-ings on this andreaffirmed hissuggestion thatfoot orthoses werelikely to be effec-tive.15

The pain ofPFPS appears to becaused, in part, byoverload of the richly-innervatedsubchondral bone, the extensorretinaculum, and the infrapatellarfat pad. Chondromalacia is a surgi-cal observation, and no longer aterm applied diagnostically to thisclinical condition.

Treatment of PFPS (Table 2)Treatment for this condition in-

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and no longer a term

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TABLE 3

Treatment Outline for ITBSRelative or absolute rest

Strengthening:Hip Abductor Muscle Strengthening—Standing hip tilts on one leg to isolate hip abductors.

Stretching:Side bends to stretch tight lateral structures, hip capsule and fibers inserting into the iliotibial band.

Ancillary stretches—adductors and rotators of hip.

Advanced stretches:Stair dipStair Strides

Optional:IceFoam roller


changes that occur during long dis-tance running may also contributeto this and other overuse injuries.Impact shock, while more oftenstudied, is not a factor. Instead, in-

creased hip ad-duction, an in-crease in kneeflexion at heelstrike, and maxi-mum knee inter-nal rotation ve-locity were foundto be higher atthe end of a runin individualswith ITBS.22

Miller’s computermodeling systemalso indicated

that tension would be greater in theITB for patients throughout thestance phase of the running gaitcycle.

Anatomical ConsiderationsThe iliotibial band (ITB) is a

continuation of the tensor fascialata as a thickening of the lateralfascia of the upper leg. A significantportion of the gluteus maximus in-serts into the ITB. Along the courseof its descent down the leg thereare connections to the linea asperaof the femur. The ITB fans out dis-tally to insert on the lateral aspectof the patella, the lateral retinacu-

sion has been noted which seemsto affect the richly vascularized andthoroughly innervated fat belowthe tendon. OnMRI a zone of sig-nal intensity ab-normality wasfound in this areaand felt to be as-sociated with in-termittent fatcompression.19,20

Tension with-in the iliotibialband was cited byNoehren et. al. asa contributingfactor, with com-pression occurring rather than fric-tion:

“The development of iliotibialband syndrome appears to be relat-ed to increased peak hip adductionand knee internal rotation. Thesecombined motions may increase ili-otibial band strain, causing it tocompress against the lateral femoralcondyle. These data suggest thattreatment interventions shouldfocus on controlling these sec-ondary plane movements throughstrengthening, stretching and neu-romuscular re-education.”21

Muscular and neuromuscular fa-tigue and the resulting kinematic

Injuries... lum and Gerdy’s tibialtubercle. Functionally thetensor fascia lata, gluteusmedius and gluteus minimusfunction as hip abductors.

Diagnosis of ITBSIliotibial band syndrome (ITBS)

is a clinical diagnosis which ismade in the presence of lateralknee pain in the general region ofthe lateral femoral epicondyle, withtenderness and pain upon compres-sion of this area while the knee isflexed and extended. Tenderness inadjacent structures, including thelateral collateral ligament of theknee and at the lateral joint line,should not be present. In earlystages, the pain might only mani-fest itself while running or follow-ing a run.

Evolution in Conceptualizationof ITBS (Summary)

The ITBS seems to be primarilycaused by overuse in the presenceof muscular imbalance. Weak hipabductor muscles are the culprit.ITBS, in most cases, is not a frictionsyndrome with a “popping” of thetendon over the femoral epi-condyle. Instead, there is a com-pression in this region that mostoften affects the fat tissue overly-ing the femoral epicondyle. Clini-cally, pain while walking and ten-derness is not always found in theearly stages. Tension does developwithin the band and early stagetendinopathic changes may be pre-sent, but no research has demon-strated this yet.

Treatment of ITBSRelative or absolute rest is an

important component of the treat-ment plan for any of these run-ning-related overuse syndromes.Directly addressing the cause of theITB syndrome, in most cases, seemsto give significant clinical success.Weak hip abductor muscles havebeen directly implicated in thiscondition. An additional factormay be tendon and capsular tight-ness. A treatment program shouldinclude hip abductor strengtheningin conjunction with lateral hip cap-sule and soft tissue stretching.

NSAIDs or ice may be used toreduce discomfort. Foam rollers and


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Quadriceps

weakness is most

often addressed in

rehabilitative

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TABLE 4

Classification of Injuries to the AchillesTendon and Surrounding Structures

Zone 1: Non-insertional Achilles InjuriesAchilles paratendinopathyAchilles tendinopathyAchilles tendinosisAchilles tendon rupture

Zone 2: Insertional Achilles InjuriesAchilles insertional tendinopathyHaglund’s TriadAchilles insertional calific tendinopathyRetrocalcaneal bursitisPre-achilles tendon bursitisAvulsion fracture of calcaneus

Zone 3:Partial tears/tears of muscle-tendinous junctionStrain of medial head of gastrocnemius musclePlantaris strain/rupture

tion. The tissue appears brown oryellow and shows disorganization,and an apparent lack of well-de-fined tightly bundled collagenfibers. Microscopic examination re-veals degenerative changes andconcomitant fibrosis.24 Ultrasoundexamination has previouslydemonstrated neovascularization inthe injured tissue.

Achilles tendon disorders areoften divided into three zones: 1)Noninsertional—the tendon proper(and paratenon), 2) conditions af-fecting the tendon insertion, and3) proximal—at the muscle tendoninterface and more structures prox-imal.25,26 An outline based onPuddu, et al., and Werd is seen inTable 4.

Evolution ofThought inInsertionalEnthesopathy

Tendinopathymay occur at theinsertion of theAchilles tendonor within themain body of thetendon itself. It ispossible thatthese two differ-ing areas may re-sult from diverse predisposing fac-tors. It has been suggested that re-peated stresses that are well withina clinical and functional range maycreate the pathology in a mannersimilar to the manner in whichbone stress reactions may occur.27

The major contributing causes cited

include overuse, ab-normal biomechani-cal factors, fluoro-quinolone antibi-otics and corticos-teroid use.

At the inser-tion of the Achillestendon, a variety ofconditions mayoccur. In additionto insertionaltendinopathy of theAchilles tendon,one may find retro-calcaneal bursitis,Haglund’s deformi-ty, and pre-tendi-nous bursitis. Whenthe Haglund’s defor-

mity is symptomatic,it is usuallyfound as a triad of insertionaltendinopathy of the Achilles ten-don, a prominent posterosuperiorcalcaneal process, and retrocal-caneal bursitis. Insertionaltendinopathy can occur in the ab-sence or presence of calcaneal bur-sitis. Numerous studies indicatethat insertional tendinopathy oc-curs in up to 5%—20% of Achillestendon overuse injuries.28 Older in-dividuals appear to be at higher riskfor this injury.28

The insertion of the Achillestendon is more complex than wethought for many years. At the os-teotendinous junction of theAchilles tendon, histological exam-ination reveals tendon, fibrocarti-

lage and bone.There are threetypes of cartilagefound here:sesamoid, pe-riosteal, and en-thesial fibrocarti-lage. The term“articular enthe-sis organ” hasbeen applied tothe insertion ofthe Achilles inview of the com-plexity of its in-

sertion (with the presence of acomplex of fibrocartilages, a fatpad, and bursae). 29) Thesesamoidal fibrocartilage is locatedat the deeper portion of the tendonand is termed such since it is with-in the tendon. The periosteal fibro-



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tissue-mobilizing massagehave been recommended. Ab-

normal biomechanical functioningof the foot and leg should be ad-dressed, including limb length dis-crepancy, but there is no evidencethat either motion-control shoes orexcessively cushioned shoes con-tribute to this condition or help toalleviate it. Table 3 outlines a treat-ment program for ITBS.

Achilles Tendinopathy

AnatomyThe Achilles tendon is the con-

tinuation of the gastrosoleus com-plex of muscles and is at the termi-nal aspect of this multijoint sys-tem. The gastrocnemius beginsabove the knee joint, the soleusbelow. The joints on which theyhave a direct impact include theknee joint, the ankle joint, and thesubtalar joint. The most distal as-pect of the insertion becomes con-tiguous with the plantar fascia. Thecomplex anatomy of the insertionis described below as an enthesisorgan.

PathologyFor years, almost all tendon

pain was lumped into the categoryof tendonitis. It was mistakenly be-lieved that inflammation was theunderlying process causing thepain and pathology in what wascalled Achilles Tendinitis. Recently,the term tendinopathy has becomethe lump-all category for tendonpathology. This term includes earlystage tendinitis, paratendinitis, andlater stage chronic tendinosis. His-tological studies have demonstrat-ed that those with chronic tendonpain do not have inflammatorychanges in the affected tendon, butrather degenerative changes.23

The term tendinosis is usedspecifically to apply to tendonswith known chronic degenerativechanges. The term tendinopathy it-self does not have this connotationand is well used to apply to overusetendon pain and swelling in the ab-sence of a histopathological diag-nosis (Maffulli, Khan, Paddu). Inlong-standing tendinopathy, at sur-gery, the tissue demonstrates theappearance of mucoid degenera-

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TABLE 5

Differential Diagnosis ofInsertional Enthesopathy

Seronegative spondyloarthropathy

Gout

Systemic steroid caused

Fluoroquinolones

Familial hyperlipidemia

Sarcoidosis

Diffuse idiopathic skeletal hyperostosis


itself. The relationship of the“spurs” here to the fibrocartilage re-mains to be detailed.

Pain is present in the back ofthe heel. The painis aggravated byrunning uphill,and by prolongedwalking, standing,or running. Table5 offers possibledifferential diag-noses of insertion-al enthesopathyof the Achillestendon.

Non-InsertionalAchillesTendinopathy

The Achilles tendon is mostoften affected in non-insertionaltendinopathy at a location 2 to 6cm. proximal to its insertion intothe calcaneus. The paratenon sub-stitutes for a true gliding synovialsheath. It is comprised of fatty areo-lar tissue surrounding the Achillestendon and is organized into amesotenon. Werd has pointed out aclinical manner of distinguishingtendinopathy from paratendinopa-thy.25 Upon palpation of thepainful area, if the foot is dorsi-flexed and plantarflexed and it isnoted that the area of maximal ten-derness does not move, the pre-sumption is that the site of tender-ness is within the paratenon itself,which is firmly attached to the sur-

cartilage is located on the opposingsuperior tuberosity of the calcaneusand is termed such since it is amodification of the periosteum.While rheumatologists began view-ing this insertion as fundamentallydifferent, the concept of enthesisorgan is only slowly breakingground in the discipline of sportsmedicine. What has been termedan insertional tendinopathy mightmore correctly be called an inser-tional enthesopathy.

An enthesis is by definition theinsertion point of a tendon, liga-ment, fascia or articular capsuleinto a bone. This area has beenfound to be impacted by drug-in-duced enthesopathies by fluoro-quinolone antibiotics (which mayalso affect the tendon prior to itsinsertion). In the case of theAchilles complex, the combinationof tendon, fibrocartilage, fat pads,and bursa may be affected at any ofthose areas, or in multiple tissuetypes, which alters function andforces.30

Fibrocartilage functions to resistshear and strains at the enthesis.This new conceptualization hasgreat and significant future implica-tions for understanding of forces,function, and treatment of Achillestendon insertional disorders.

Bone spurs which form at thislocation have been noted to not bewithin the substance of the tendon

Injuries... rounding tissues anddoes not move. If the ten-derness shifts with dorsiflex-ion and plantarflexion, the ten-

derness isdeemed to bewithin the tendi-nous tissue.

Additional CalfInjuries

Injuries torunners are alsonoted at the my-otendinous junc-tion, within thecalf muscle itself,and to the plan-taris.

Approach to TreatmentConservative treatment is di-

rected to decreasing strain on thetendon and allowing the tissue torepair itself. Relative rest, absoluterest or the use of a pneumatic walk-ing boot may be required. NSAIDsare often used, and offer a decreasein symptoms and a more normalgait and motion pattern throughpain reduction, although their anti-inflammatory effects are no longerthought to be of assistance.

Cross friction massage and iceapplication are often used. Themodalities of ultrasound and highvoltage galvanic stimulation mayalso be helpful. Heel lifts, and pos-sible custom functional foot or-thotics may also assist in reducingmechanical strain.

After the pain is reduced, a gen-tle and gradual return to activityand then speed is helpful. Avoidinghills or inclined treadmills is ad-vised. Excessively cushioned shoes,which will increase the eccentricforces within the tendon, should beavoided.

Alfredson has proposed the useof eccentric stretching andstrengthening with heavy loads,which when performed as de-scribed, is meant to cause pain.31,32

Similar approaches have been sug-gested for several othertendinopathies, including patellartendinopathy. Two review articlesexamining eccentric strengtheningas treatment for a number of ten-dons were recently published.33 Theauthors thought, in general, that


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may occur at the

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Achilles tendon or

within the main body

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TABLE 6

Treatment Suggestions for AchillesTendinopathy

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

Immobilization vs. Eccentric Stretching

Ice—symptomaticHeel lift to reduce strain deformation and loads at the insertion.

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

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

Injuries of this nature were firstnoted by Briethaupt, a militaryphysician, in 1855, who notedswelling and pain in the feet ofPrussian military recruits.36 In 1897,radiographic examination revealedthe nature of the injury and“march fracture” entered the litera-ture as reported by Stewchow.37 Anumber of studies have followedwhich detail this injury in both amilitary population and within theathletic population. Estimates ofthe occurrence in the running pop-ulation is that as many as 10% ormore of injuries may be stress reac-

tions in bone.38

BackgroundBone is a dy-

namic structure.As a biologicalmaterial, it is sub-ject to change asa result of envi-ronmental stim-uli and in re-sponse to geneticpredilection. Theinitial injurymight be a bio-

logical or biochemical abnormalityor failure at the cellular or bonemulticellular unit (BMU) level.Bone adapts to many levels of in-termittent, repetitive compressiveand tension strains by an increasein density. In the presence of ab-normally high and repetitive forces,

the abilityto heal bym i c r o -d a m a g erepair isnot ade-q u a t e ,and mored a m a g ethan re-pair oc-curs.39 Inshort, anexcessivea m o u n tof stressor repeti-tive stressis occur-ring with-out thebone hav-ing ade-quate rest

to allow for adaptation to thestress. In essence, the stress thatcreates these injuries is too much,too soon for the bone.

It is important to keep in mindother contributing factors in thedevelopment of RSI of bone. Be-sides training errors and the biome-chanical causes that we usuallythink of, a variety of systemic con-ditions can contribute to this in-jury. These factors include osteope-nia, osteoporosis, other metabolicbone disorders, hormonal abnor-malities, inadequate nutritional in-take, and collagen disorders. Inwomen, amenorrhea or oligomen-orrhea may lead to deficient estro-gen and low bone mineral density.The female athlete triad includeslow bone density by definition,along with disordered eating andamenorrhea.40 Overtraining maylead to decreased testosterone levelsin men resulting in osteopenia. Pa-tients of either gender having mul-tiple stress fractures should likelyhave a bone density (DEXA) scanperformed.

DiagnosisInitial suspicion of a repetitive

stress injury of bone (RSIB) or stressreaction often leads to the clinicaldiagnosis. The patient’s history ofinjury, changing pattern of exer-cise, physical examination, andimaging studies lead the practition-



Injuries...

the evidence was weak andunderpowered.The current literature was de-

scribed as having a “dearth of highquality research in support of theclinical effectiveness of EE (eccen-tric exercise) over other treatmentsin the management oftendinopathies.”33 Kingma, et al.agreed, that while the techniqueappeared promising “large method-ologically sound studies ….are war-ranted.”34

For severe, chronic, and un-remitting tendinosis, surgery re-mains an option. The described sur-gical procedures include strippingof the paratenon, linear teno-tomies, and excision of non-viabletissue.28,35

Treatment for Achillestendinopathy is outlined in Table 5.

Stress Fractures and StressReactions of Bone: A ChronicRepetitive Stress Injury

DefinitionThe term stress fracture, while

commonly used, does not representthe nature and diversity of this fre-quently found overuse injury.Repetitive stress injury (RSI) ofbone, or stress reaction, are bothbetter suited to describe this injury.The majority of injuries that are di-agnosed as stress fracture do notdemonstrate a fracture line andshould not betermed a fracture.More severe stressinjuries are simi-lar to what istermed fatiguefractures in othermaterials. Itshould be notedthat bone hasbeen found to failmore frequentlyin tension than incompression.

In runners,the most frequently injured bonesare the tibia, metatarsals, and calca-neus. The available data on theother bones offers varying data, butvirtually all lower extremity bonesmay be affected, including thefemur, navicular, fibula, cuboid,and cuneiforms.

Contin

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An enthesis is by

definition the

insertion point of a

tendon, ligament,

fascia or articular

capsule into a bone.

TABLE 7

Differential Diagnosis of LowerExtremity Stress Fracture

Conditions that may appear to be a stress fracture

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


tion in a pneumatic walker for fourto six weeks or more is often help-ful for tibial stress fractures, and avariety of other stress injuries ofbone.42 Calcaneal stress fracturesmay be suspectedwhen there is ten-derness upon lat-eral compressionof the body,rather than at themedial calcanealtuberosity or ten-derness that isonly plantar tothe calcaneus.

In a group ofmilitary recruits,the majority(56%) of cal-caneal stress reac-tions occurred inthe posteriorthird of the boneand 79% occurredin the upper half of the calcaneus.43

Earlier reviews noted that the in-jury occurred primarily in the pos-terior aspect of the calcaneus, butSormaala notes the importance ofsuspecting a stress reaction in the

er to the diagnosis. The classicalpresentation is in an athlete pre-senting with sudden onset of painduring or after a run. Usually, therehas been a discernable change intraining habits. Mileage may haveincreased, twice a day runs begun,speed work initiated, a new pair ofrunning shoes used, or there hasbeen aging of running shoes alongwith any other contributing factor.Physical examination will usuallyreveal a discrete area of tenderness.Certain bones are not as accessibleto palpation as others are. Thepelvic bones, femur, talus, and mid-tarsal bones are notoriously diffi-cult to palpate and examine clini-cally. So, a high level of suspicionmust be present to reach the diag-nosis particularly in the rearfootand midfoot; and the use of imag-ing should be considered.41

On the tibia, as is mentionedelsewhere in this article, a horizon-tal line of tenderness is often thedifferentiating clinical sign fromthe vertical tenderness of medialtibial stress syndrome. Immobiliza-

Injuries... more anterior portion ofthe bone. Stress fractures ofthe tarsal navicular should besuspected when there is dorsaltenderness extending proximally to

distally. In addi-tion to simpletenderness, ten-derness to percus-sion or to the vi-brations of a tun-ing fork havebeen used aspathognomonicsigns.

D i a g n o s t i cimaging includesradiographic eval-uation, tech-netium-99 bonescan, and MRI.Often, an injuryis not visible onradiographic ex-amination. Bone

scintigraphy is considered sensitive,while MRI is considered to be bothsensitive and specific.41 At earlystages, the MRI shows marrowedema as an increased STIR signaland in fat-suppressed T2 images.On T1 sequences, a decreased signalis noted.44 As the injury progressesto a stage of increasing severity, alow signal fracture line and bonecallus may be visible.

A number of conditions mayconfound diagnosis and appearsimilar to stress fracture on certainimaging studies (Table 7). In othercases, asymptomatic bone marrowedema may be visible on MRI.41

TreatmentConservative treatment works

well for most RSI of bone. The keyis finding the appropriate mechani-cal treatment to eliminate the painof weight bearing. With the elimi-nation of pain, the forces should besufficiently low for healing and re-modeling to take place. Weight-bearing exercise should be avoided.Multiple authors have recommend-ed the use of a pneumatic walkerfor tibial stress fractures.42,45 Thismay be used alone or with crutch-es, as needed. A cam walker, pneu-matic walker or low pneumaticwalker may alleviate pain faster andbe clinically superior to a post-oper-ative shoe for stress reactions of the


Continuing

Medical Education

The Achilles tendon is

most often affected in

non-insertional

tendinopathy at a

location 2 to 6 cm.

proximal to its

insertion into the

calcaneus.

TABLE 8

Pribut Pain Staging of Overuse Injuries in Athletes

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

Stage 1—Pain or stiffness after activity. The pain is usually gone by thenext day.

Stage 2—Mild discomfort before activity that goes away soon afterexercise is commenced. No pain is present in the latter part ofthe exercise. Pain returns after the exercise is completed(starting within 1 to 12 hours later and lasts up to 24 hours).

Stage 3—Moderate pain is present before sport. Pain is present duringsport activity, but is somewhat decreased. The pain is anannoyance which may alter the manner in which the sport isperformed.

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

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

below the knee, the front part ofthe tibia, or the lower leg itself. Wewill omit consideration of anteriortibial leg pain and review the medi-al portion of the tibia that the termmedial tibial stress syndrome(MTSS) refers to.

Historically included entitieswithin the realm of MTSS include:

periostitis, trac-tion periostalgia,tendinopathy, pe-riosteal reaction,and fatigue fail-ure of the con-nective tissueconnecting mus-cle to bone.49

Where is thePain?Symptoms andDescription

By definition,the pain in MTSS

occurs at the posteriomedial aspectof the tibia. Edwards has detailedan algorithmic approach to diagno-sis and confirmatory tests to differ-entiate MTSS from nerve injury andcompartment syndrome.50 He sug-gests that MTSS may occur more

often in the distalthird of the tibia,and one shouldconsider stressfracture moreproximally. Whilehis flow chart isinteresting, it isseverely flawed.MTSS is consid-ered as a strongpossibility withpain at rest in thepresence of palpa-ble tenderness. Inthe absence ofpain at rest, butwith palpable ten-derness, he con-siders common orsuperficial nerveentrapment as thelikely cause oflower limb pain.

Unfortunate-ly, in the contextof treating run-ners, this makeslittle sense. Henotes elsewhere inhis article that the

pain in the early stages does fadewith rest. Previous observations ofoveruse injuries and pain-stagingbetter and more accurately definethe pain seen with this condition.51-

53 See Table 8 for a staging of painoccurring in overuse injuries. Nervecompression or entrapment syn-dromes are usually consideredwhen the history includes the de-scription of pain that is burning innature and may be associated witha subjective or objective observa-tion of numbness. Exertional com-partment syndromes, which pre-sent with a somewhat different setof symptoms, will not be reviewedwithin this paper.

Michael and Holder54 describedthe clinical characteristics of earlyMTSS as including:

1) Induced by exercise, relievedby rest;

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

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

Risk FactorsThacker49 reviewed the avail-



Injuries...

metatarsal area, and for otherfoot stress reactions.During recovery, one should

guide the athlete to appropriatecross-training activity. Swimming,bicycling, and maintenance ofupper body strength should be im-plemented. Lower extremity exer-cises should be chosen as appropri-ate, and if deemed to not risk de-layed healing or further injury.

A phased return to activity, al-lowing sufficient time for healing,is the key to a successful return toactivity. In clinical practice, the au-thor has found that weaning fromthe pneumatic walker seems tolessen the time to comfortable exitfrom the walker and prevent painfrom returning and the necessity ofreturning to the use of the pneu-matic walker. Most lower-extremitystress reactions take between 8 and17 weeks for recovery.38

Medial Tibial Stress Syndrome(Shin Splints)

Shin splints, the term that justwon’t die, is gradually fading fromuse. The terms anterior shin splints,posteromedial shin splints, and ahost of other terms came intovogue in the 1970’s and 1980’s. Aslong ago as 1967, Slocum encour-aged the abandonment of the termshin splints from the medical litera-ture.46 Ten years later, James alsosupported the efforts to eliminatethe term suggest-ing posterior tib-ial syndrome asan alternative.47

More recentlythe improved de-scriptive termmedial tibialstress syndrome iscoming into com-mon use. Theterm was first ap-plied by R. Drezand popularizedby Mubarak in1982.48 This termis appropriate to use in the absenceof a stress fracture or an exertionalcompartment syndrome. The olderterm, shin splints, never madeclear what part of the leg was af-fected. Some have considered theshin to be the front part of the leg

Contin

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In runners, the

most frequently

injured bones are the

tibia, metatarsals,

and calcaneus.

TABLE 9

Selected Entities Causing Plantar Heel Pain

MechanicalPlantar Fasciopathy

Repetitive TraumaStress fracturesRupture of plantar fascia

NeurologicalPosterior tibial nerve—tarsal tunnel syndromeMedial calcaneal nerveMedial plantar nerveLateral plantar nerve

ArthriticSeronegative SpondyloarthropathiesRheumatoid ArthritisFibromyalgiaGout

Misc.InfectionBone cyst or tumorApophysitis


al., found metabolic changes inbone with no inflammation andbelieved MTSS to be a stress reac-tion of bone. Other theorists haveproposed traction injury at the pos-terior tibialis and/or soleusmuscles.54

Bates in 1985 postulated thatexcessive pronation and eccentriccontraction of the soleus and poste-rior tibial muscles were contribut-ing factors in the development ofMTSS.56 Factors that increase bend-ing moments or traction at thesesites include a planus foot type,tarsal coalition, leg length inequali-ty, and muscle imbalance.57

The tibialis posterior muscle ori-gin has been noted to be in theupper two thirds of the interosseusmembrane, medial fibula, and later-al tibia. It is somewhat proximal towhere the bulk of the tenderness is

usually noted clinically. Beck andOsternig performed cadaver dissec-tions which demonstrated that thesoleus, flexor digitorum longus anddeep crural fascia were close to theusual areas in which symptomswere found and the posterior tib-ialis muscle was found a consider-able distance proximally.58 In spiteof the downplaying of the tibialisposterior by its anatomical posi-tion, under eccentric contraction,Pribut postulates that it should stillsubstantially increase the strain inthe medial tibia.

Bouché and Johnson re-searched traction resulting uponthe tibial fascia when forces areapplied to the posterior tibial,soleus, and f lexor digitorumlongus tendons.59 In their discus-sion, they noted that these mus-cles eccentrically contract duringstance to counter midtarsal andsubtalar joint pronatory forces,

able epidemiological literature andfound a general consensus thatthere were a variety of potentialrisk factors detailed in the litera-ture. The risk factors most oftencited include: younger age, femalegender, change in distance, fre-quency, speed, surface of runs,change of running shoes, excesspronation, and a previous historyof injury. As is often the case inthe medical literature, contrarystudies are often found. Contrarystudies are also cited on age, gen-der, mileage, hill running, run-ning surface, previous activitylevel and flexibility. In our con-stant quest for high level studiesthat are reliable and meet the re-quirements of evidence-basedmedicine, we often find ourselveswandering in the mire of the liter-ature and decide that the evidenceis thin for much of what we thinkwe know. We remain with theknowledge of the importance ofhaving a basic understanding ofcausative factors in the context ofcarefully assessing an individualpatient.

ImagingWhile clinical signs and symp-

toms will lead you to the diagnosisin many cases, it still may be help-ful to rule out a stress fracture. Ra-diographs should be taken in ques-tionable cases, but they are ofteninsufficiently sensitive to showmany stress fractures and offer noinformation that would demon-strate MTSS.

Both triphasic bone scans (dif-fuse, superficial, linear uptake) andMRI (diffuse linear signal on T2)have been used to demonstratestress fracture and, in many cases,they may demonstrate linear pat-terns suggesting MTSS; althoughnegative studies do not precludethe diagnosis of MTSS.

MTSS—CausesThere are a variety of theories of

the pathogenesis of MTSS. Periosti-tis was one widely believed to bethe cause of the pain, but histologi-cally inflammation was notfound.55 Periostalgia has been ap-plied to pain at this site in the ab-sence of inflammation. Johnell, et

Injuries... which earlier had beenlinked to MTSS.60 Bouchéand Johnson’s study demon-strated a direct linear relation-ship between forces applied tothose muscles and strain mea-sured at the muscle bone inter-face, and the conclusion theyreached was that “eccentric con-traction of the superficial anddeep flexor tendons of the leg isthe key pathomechanical factor…” in the creaton of MTSS. 59

Bouché also noted that exercisingon hard floors had been found toincrease eccentric contractions ofthese muscles. The research ofBouché sits well with the con-cepts earlier espoused by Michael,et al. in their article entitled “TheSoleus Syndrome.”54 Michael’ssuggestion that the soleus couldcontribute to “shin splints” wasbased on cadaver, EMG, and mus-cle stimulation research.

Treatment and PreventionThus far, a number of studies

have surprisingly failed to showprevention from graded increase inexercise programs. There are anumber of possible experimentaldesign measures that might showdifferences better, but at this pointthe evidence that would back upcommon sense is not there. Thack-er notes serious “methodologicalflaws” in the studies he reviewed.49

It is important to include restand relative rest at the top of rec-ommendations. Two to four weeksof rest may alleviate much of thepain in early MTSS. Training alter-ations prior to the development ofMTSS need to be carefully analyzedand recommendations should bemade based upon this analysis. Abiomechanical analysis of the lowerextremity should be performed,and shoe and custom orthotic rec-ommendations are made asneeded.50 Excessive pronation hasbeen found to be a contributingfactor.

NSAIDS, while not directly ad-dressing inflammation, are usefuladjuncts to pain control and allowthe early resumption of normalmotion patterns and strengtheningand stretching exercises. Gas-trosoleus stretching should be un-dertaken. Core muscle strengthen-


Continuing

Medical Education

Shin splints,

the term that

just won’t die, is

gradually fading

from use.

ditions of pain in this region inboth the absence and presence ofan inferior calcaneal spur.

The origin of the plantar fasciais an enthesis similar to the Achillestendon. Fibrocartilage is found atits site of origin. Growing heelspurs appear to take shape deep tothe plantar fascia and have beennoted to grow within developing

cartilage via en-dochondral andintramembranousossification, mostlikely at the siteof the enthesisand in close asso-ciation with theflexor digitorumbrevis.63 Newthinking is thatthis is not a trac-tion injury but ane n t h e s o p h y t eformed in the en-thesis via stimula-

tion of the bone by stress. Pributhas hypothesized that even in theabsence of direct traction injury atthe site of origin of the plantar fas-cia, there will be sufficient strain inthe enthesis and in the calcaneus tostimulate bone and cartilage pro-duction and sufficient strain to alsocreate other calcaneal stress in-juries. Early changes occurring inthe enthesis fibrocartilage near thecalcaneal surface include the ap-

pearance of cartilage cell clustersand longitudinal fissure formationwith erosion of subchondral bone.

SymptomsPain upon arising in the morn-

ing is one of the hallmarks of plan-tar heel pain syndrome. The painis noted to be on the plantar orplantar medial aspect of the heel.Tenderness is usually found uponpalpation of the medial calcanealtuberosity. It is important to dis-tinguish plantar fasciitis from atear of the plantar fascia, whichmost often occurs 2-6 cm anteriorto the origin of the plantar fasciaand from a calcaneal stress frac-ture. The tenderness of most cal-caneal stress fractures is linear andfound on the body of the calca-neus, often on both the medialand lateral sides. Nerve entrap-ment may also cause pain in thisregion. Table 9 details some of theclinical entities that can causeplantar heel pain.

TreatmentEntire issues and seminars are de-

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



Injuries...

ing is becoming increasinglyused for a variety of lower ex-

tremity overuse injuries and shouldbe evaluated for strength deficit.

During the rest period, the ath-lete will need to be given a programof alternative exercise. This mayconsist of low impact cardiovascu-lar exercises such as swimming, sta-tionary bicycle, or pool running. Itmay be supplemented with upperbody weight training. Gradual re-turn to activity and incrementallybuilding up distance and intensityshould assist in a smooth return tonormal activity.

Plantar Fasciopathy, PlantarHeel Pain Syndrome

Plantar fasciitis is one of themost frequently found foot injuriesamong runners. As with severalother entities, we are discoveringthat many of the terms we havecalled this by are likely incorrect.The heel pain we most often seehas been called many things in-cluding plantar heel pain, heel spursyndrome, and recently plantarheel pain syndrome.61 In the termfasciitis, the -itis ending denotes aninflammation. Perhaps if we rede-fined -itis, we could still use fasciitisand tendonitis,but the death ofthe term plantarfasciitis is rapidlyapproaching.

Lemont exam-ined specimensand found no in-flammation pre-sent. Instead, hefound changesanalogous to thatfound in tendi-nosis: myxoid de-generation, colla-gen degeneration,increased vascularization, and vas-cular engorgement of the adjacentbone marrow.62 Evidence of inflam-mation was not seen. WhileLemont indicated that plantar fasci-itis should be considered plantarfasciosis, this latter term is probablybest termed fasciosis after biopsy,and plantar fasciopathy is a moresuitable term.

The term plantar heel pain syn-drome can be used to include con-

Contin

uing

Medica

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By definition,

the pain in MTSS

occurs at the

posteriomedial

aspect of the tibia.

TABLE 10

Outline of TreatmentRecommendations for Plantar Heel

Pain Syndrome

Relative or Absolute RestStretchingCryotherapyNSAIDs (for pain, not inflammation)Night splintsOTC InsertCustom Foot orthosesShoes—torsion & flexion stabilityCheck Stability of running and walking shoes, replace if necessaryAvoid barefoot walkingAvoid calf raises and stair dips and other forefoot-only contact exercises


medicine in a face-to-face setting, Iencourage you to attend lectures onthese topics. Venues which includeinformation of interest to the pod-iatric sports medicine physician in-clude the Annual APMA ScientificSeminar featuring a track put on bythe AAPSM, regional meetingswhich feature the AAPSM and a va-riety of lecture series at the podia-tric medical colleges which arejointly put on with the AAPSM. In-formation on these meetings can befound at the website of the AAPSM(www.aapsm.org). ■

References1 President’s_Council_on_Physi-

cal_Fitness. Physical FitnessFacts/Healthy People 2010. 2007 (cited

2008 1/08/2008).2 Willems, T.M., et al., Gait-relat-

ed risk factors for exercise-relatedlower-leg pain during shod running.Med Sci Sports Exerc, 2007. 39(2): p.330-9.

3 Chorley, J.N., et al., Baseline in-jury risk factors for runners starting amarathon training program. Clin J SportMed, 2002. 12(1): p. 18-23.

4 van Gent, R.N., et al., Incidenceand determinants of lower extremityrunning injuries in long distance run-ners: a systematic review. Br J SportsMed, 2007. 41(8): p. 469-80; discussion480.

5 Hreljac, A., Etiology, preven-t ion, and ear ly intervent ion ofoveruse injuries in runners: a biome-chanical perspective. Phys Med Reha-bil Clin N Am, 2005. 16(3): p. 651-67, vi.

6 Kelsey, J.L., et al., Risk factors for

For early heel pain of less thansix weeks duration, the most fre-quent recommendations were foravoidance of walking barefoot orwalking in flat shoes, over thecounter inserts, regular calf stretch-ing, cryotherapy, non-steroidal,anti-inflammatory drugs (NSAIDs),and strapping of the foot. At an in-termediate stage, when pain hasbeen present for six weeks to sixmonths, the respondents usuallyrecommended a custom orthotic.Corticosteroid injections were alsofrequently recommended—al-though, in view of Lemont’s find-ings, the rationale of such injectionsneeds to be reconsidered.62 Nightsplints were also sometimes used.

Additional measures recom-mended for late stage plantar fas-ciopathy include immobilizationvia the use of a cast or pneumaticwalker, plantar fasciotomy, and ex-tracorporeal shockwave therapy.

It is important to examine yourpatient’s running shoe to make cer-tain that flexion and torsional sta-bility is present. If the shoe is exces-sively flexible, more forces will becreated within and near the plantarfascia, most likely via the windlasseffect. If the pain has been severeenough to cause the patient to missseveral weeks’ worth of running, aslow and gradual return is impor-tant to avoid recurrence of injuryor a new overuse injury. Intrinsicmuscle strengthening and calf mus-cle stretching need to be performedby the athlete regularly. An outlineof treatment recommendations fol-lows in Table 10.

SummaryThe study and quest for under-

standing athletic injuries is a life-long undertaking. We have tried togive a picture of some of the mostcommon running injuries in thisarticle and to detail the evolutionof thought that has occurred overthe last few decades on these com-monly seen but still little under-stood clinical entities. We hopeyour interest has been piqued tocontinue learning about these mal-adies and that you develop amethod of assessing the literatureto better treat your patients. To en-hance your knowledge of sports

Injuries... stress fracture among youngfemale cross-country runners.Med Sci Sports Exerc, 2007.39(9): p. 1457-63.

7 Buist, I., et al., No Effect of aGraded Training Program on the Num-ber of Running-Related Injuries inNovice Runners: A Randomized Con-trolled Trial. Am J Sports Med, 2008.36(1): p. 33-39.

8 Powers, C.M., et al., Role of Peri-patellar Retinaculum in Transmission ofForces Within the Extensor Mechanism.J Bone Joint Surg Am, 2006. 88(9): p.2042-2048.

9 Senavongse, W. and A.A. Amis,The effects of articular, retinacular,or muscular def ic iencies onpatellofemoral joint stability. J BoneJoint Surg Br, 2005. 87-B(4): p. 577-582.

10 Goh, J .C. , P .Y. Lee, and K.Bose, A Cadaver Study of the Func-tion of the Oblique Part of VastusMedialis. J Bone Joint Surg Br, 1995.77-B: p. 225-231.

11 Merchant, N.D. and C. Bennett,Recent Concepts in patellofemoral in-stability. Curr Opin Orthop, 2007. 18: p.153-160.

12 Cichanowski, H., et al., HipStrength in Collegiate Female Ath-letes with Patellofemoral Pain. MedSci Sports Exerc, 2007. 39(8): p. 1227-1232.

13 Tyler, T.F., et al., The role ofhip muscle function in the treatmentof patellofemoral pain syndrome. AmJ Sports Med, 2006. 34(4): p. 630-6.

14 Sheehan, G., Dr. Sheehan onRunning. 1975, Mountain View:World Publications.

15 Powers, C.M., et al., Comparisonof foot pronation and lower extremityrotation in persons with and withoutpatellofemoral pain. Foot Ankle Int,2002. 23: p. 634-640.

16 Saxena, A. and J. Haddad, TheEf fect of Foot Orthoses onPatellofemoral Pain Syndrome. J AmPodiatr Med Assoc, 2003. 93(4): p.264-271.

17 Fredericson, M. and C. Wolf,Iliotibial band syndrome in runners:innovations in treatment. SportsMed, 2005. 35(5): p. 451-9.

18 Fairclough, J., et al., Is iliotibialband syndrome really a friction syn-drome? Journal of Science and Medicinein Sport, 2007. 10(2): p. 74-76.

19 Fairclough, J., et al., The func-tional anatomy of the iliotibial bandduring flexion and extension of theknee: implications for understanding ili-otibial band syndrome. Journal ofAnatomy, 2006. 208(3): p. 309-316.

20 Muhle, C., et al., Iliotibial BandFriction Syndrome: MR Imaging Find-


Continuing

Medical Education

The term plantar heel

pain syndrome can be

used to include

conditions of pain in

this region in both the

absence and presence

of an inferior

calcaneal spur.

and nonelite track athletes. Foot AnkleInt, 2003. 24.

36 Breithaupt, J., Zur pathologie desmenschlichen fussess. 1855; 24:169-177.Medizin Zeitung, 1855. 24: p. 169-177.

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

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

39 Akkus, O. and C.M. Rimnac,Cortical bone tissue resists fatiguefracture by deceleration and arrest ofmicrocrack growth. J Biomech, 2001.34: p. 757-764.

40 Lebrun, M., The Female AthleteTriad: What’s a Doctor to Do? Cur-rent Sports Medicine Reports, 2007.6: p. 397–404.

41 Niva, M.H., et al., Bone stressinjuries of the ankle and foot: an 86-month magnetic resonance imaging-based s tudy of phys ica l ly act iveyoung adults. Am J Sports Med, 2007.35(4): p. 643-9.

42 Swenson, E.J., et al., The Effectof a Pneumatic Leg Brace on Returnto Play in Athletes with Tibial StressFractures. Am. J. Sports Med., 1997.25(June): p. 322-328.

43 Sormaala, M.J., et al., Stress In-juries of the Calcaneus Detected withMagnetic Resonance Imaging in Mili-tary Recruits. J Bone Joint Surg Am,2006. 88: p. 2237-2242.

44 Stafford, S.A., D.I. Rosenthal,and M.C. Gebhardt, MRI in StressFracture. AJR Am J Roentgenol, 1986.147: p. 553-556.

45 Fredericson, M., et al., Tibialstress reaction in runners. Correlation ofclinical symptoms and scintigraphywith a new magnetic resonance imaginggrading system. Am J Sports Med, 1995.23(4): p. 472-81.

46 Slocum, D.B., The shin splintsyndrome. Am J Surg, 1967. 114: p.875–881.

47 James, S.L., B.T. Bates, and L.R.Osternig, Injuries to Runners. Am JSports Med, 1978. 6: p. 40-50.

48 Mubarak, S.J., et al., The Medi-al Tibial Stress Syndrome: A Cause ofShin Splints. Am J Sports Med, 1982.10(4): p. 201-205.

49 Thacker, S.B., et al., The preven-tion of shin splints in sports: a system-atic review of literature. Med Sci SportsExerc, 2002. 34(1): p. 32-40.

50 Edwards, P.H., M.L. Wright,and J.F. Hartman, A Practical Ap-proach for the Differential Diagnosisof Chronic Leg Pain in the Athlete.Am J Sports Med, 2005. 33: p. 1241-1249.

51 MacIntyre, J.G., J.E. Taunton, andD.B. Clement, Running injuries: a clini-cal study of 4,173 cases. Clin J Sport

Med, 1991. 1(2): p. 81-87.52 O’Connor, F.G., T.M. Howard,

and C.M. Fieseler, Managing OveruseInjuries: A Systematic Approach. Phy-sician & Sportsmedicine, 1997. 25(5):p. 11.

53 Pribut, S.M., A Quick Look AtRunning Injuries. Podiatry Manage-ment, 2004. 23(1): p. 57-68.

54 Michael, R.H. and L.E. Holder,The Soleus Syndrome. Am J Sports Med,1985. 13(2): p. 87-94.

55 Detmer, D.E., Chronic shinsplints. Classification and managementof medial tibial stress syndrome. SportsMed, 1986. 3(6): p. 436-46.

56 Bates, P., Shin splints—a litera-ture review. Br J Sports Med, 1985.19(3): p. 132-7.

57 Sommer, H.M. and S.W. Val-lentyne, Effect of foot posture on theincidence of medial tibial stress syn-drome. Med Sci Sports Exerc, 1995.27(6): p. 800-804.

58 Beck, B.R. and L.R. Osternig, Me-dial tibial stress syndrome. The locationof muscles in the leg in relation tosymptoms. J Bone Joint Surg Am, 1994.76(7): p. 1057-1061.

59 Bouche, R.T. and C.H. Johnson,Medial Tibial Stress Syndrome (TibialFasciitis): A Proposed PathomechanicalModel Involving Fascial Traction. J AmPodiatr Med Assoc, 2007. 97(1): p. 31-36.

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

61 Pr ibut , S .M. , Current Ap-proaches to the Management of Plan-tar Heel Pain Syndrome, Includingthe Role of Injectable CorticosteroidsJ Am Podiatr Med Assoc, 2007. 97(1):p. 68-74.

62 Lemont, H., K. Ammirati, and N.Usen, Plantar Fasciitis A DegenerativeProcess (Fasciosis) Without Inflamma-tion. J Am Podiatr Med Assoc, 2003.93(3): p. 234-237.

63 Kumai, T. and M. Benjamin, Heelspur formation and the subcalcaneal en-thesis of the plantar fascia. J Rheumatol,2002. 29(9): p. 1957-64.


Injuries...

ings in 16 Patients and MRArthrographic Study of Six Cadaver-

ic Knees. Radiology, 1999. 212(1): p.103-110.

21 Noehren, B., I. Davis, and J.Hamill, ASB Clinical BiomechanicsAward Winner 2006. Prospect ivestudy of the biomechanical factorsassociated with iliotibial band syn-drome. Clin Biomech (Bristol, Avon),2007. 22(9): p. 951-956.

22 Miller, R.H., et al., Lower ex-tremity mechanics of iliotibial bandsyndrome during an exhaustive run.Gait Posture, 2007. 26(3): p. 407-13.

23 Movin, T., et al., Tendon patholo-gy in long-standing achillodynia. Biopsyfindings in 40 patients. Acta OrthopScand, 1997. 68(2): p. 170-5.

24 Khan, K.M., et al., Histopathol-ogy of common tendinopathies. Up-date and implications Sports Med,1999. 27: p. 393-408.

25 Werd, M., Achil les TendonSports Injuries. J Am Podiatr MedAssoc, 2007. 97(1): p. 37-46.

26 Puddu, G., E. Ippolito, and F.Postachini , A c lass i f icat ion ofAchilles Tendon Disease. Am J SportsMed, 1976. 4.

27 Rees, J., Wilson, AM, Wolman,RL, Current concepts in the manage-ment of tendon disorders. Rheuma-tology, 2006. 45: p. 508-521.

28 Mafful l i , N. and L .C.Almekinders, The Achilles Tendon.2007, London: Springer-Verlog.

29 Benjamin, M., et al., The “en-thesis organ” concept: Why ente-sopathies may not present as focal in-sertional disorders. Arthritis Rheum,2004. 50(10): p. 3306-3313.

30 Slobodin, G., et al., Varied Pre-sentations of Enthesopathy. SeminArthritis Rheum, 2007. 37(2): p. 119-126.

31 Alfredson, H., et al., Heavy-loadeccentric calf muscle training for thetreatment of chronic Achilles tendi-nosis. Am J Sports Med, 1998. 26(3): p.360-6.

32 Alfredson, H. and J. Cook, Atreatment algorithm for managingAchilles tendinopathy: new treatmentoptions. Br J Sports Med, 2007. 41(4):p. 211-216.

33 Woodley, B.L., R.J. Newsham-West, and D.B. Baxter, Chronictendinopathy: effectiveness of eccentricexercise. Br J Sports Med, 2007. 41: p.188-199.

34 Kingma, J.J., et al., Eccentric over-load training in patients with chronicAchilles tendinopathy. Br J Sports Med,2007. 41:e3(6).

35 Saxena, A., Results of chronicAchilles tendinopathy surgery on elite

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Dr. Pribut is aClinical Assis-tant Professorof Surgery atGeorge Wash-ington Universi-ty MedicalSchool. He is apast presidentof the AmericanAcademy ofPodiatric Sports Medicine. He is in pri-vate practice in Washington, DC.


B) Patellofemoral pain syn-dromeC) chondromalacia patellaeD) runner’s meniscus

7) Evidence in studies has indicat-ed that a large contributing factorto iliotibial band syndrome is:

A) weak hip abductor musclesB) over pronation of the footC) high archesD) soft shoes

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

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

9) The most frequently occurringAchilles tendon injuries in runnersare best termed

A) Achilles tendonitisB) AchillocytisC) Achilles bursitisD) Achilles tendinopathy

10) All of the following types offootgear could aggravate pain inthe Achilles tendon area except:

A) negative heel shoesB) firm heel shoe, flexible atball, with 1/4” heel liftC) well-cushioned shoesD) shoes with a stiff and hard-to-bend sole.

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

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

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

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

2) Diffuse activity along the pos-teriomedial aspect of the tibia vis-ible on bone scintigraphy proba-bly indicates:

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

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

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

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

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

5) Factors considered importantto the development ofpatellofemoral pain syndrom include:

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

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

A) Runner’s Knee

12) The histological findings oftendinosis include:

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

13) Stress fractures of the tibiado not usually demonstrate:

A) horizontal line of tendernessB) diffuse linear vertical uptake on scintigraphyC) negative findings on x-rayD) focal area of concentrat-ed uptake in proximal 1/3of tibia on scintigraphy

14) In the detection of stressfractures of the lower extremi-ty, the following imaging studyis considered sensitive and specific:

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

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

A) is best treated with corti-costeroid injectionsB) is most often a stressfractureC) is caused by a tight or a weak anterior tibialis muscleD) often falls into the cate-gory of posterior tibialstress syndrome

16) The following statementabout patellofemoral pain dis-order is false:

A) the preferred name of

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132 PODIATRY MANAGEMENT

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

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

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

18) Surgical treatment of Achilles tendinosis mostcommonly would likely include any of the follow-ing except:

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

19) The tibialis posterior muscle originates fromthe:

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

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

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

E X A M I N A T I O N

(cont’d)

See answer sheet on page 133.

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What overall grade would you assign this lesson?

A B C D

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1. A B C D

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4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D

12. A B C D

13. A B C D

14. A B C D

15. A B C D

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18. A B C D

19. A B C D

20. A B C D

Circle:

EXAM #4/08The Top Five Running Injuries

Seen in the Office(Pribut)

Apr08 p117-134 CME-BG · PFPS and iliotibial band syndrome. 3) Review the significance of...

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