Section: CME Category: Trauma & Sports Medicine

A Sports Medicine Approach to Treating Common Foot Injuries

Jay Spector, DPM

Jay Spector, DPM discusses old versus new treatments for sports medicine pathologies with evidence-based research. Dr Spector also discusses how a sports medicine approach can help identify underlying pathology that will help with the success of patients looking past the present illness and more at a long-term plan to prevent recurrence.

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Goals and Objectives
  1. Review old treatments for plantar fasciitis, Achilles tendonitis, and shin splints
  2. Review new treatments for plantar fasciitis, Achilles tendonitis, and shin splints with evidenced based research
  3. Report how a sports medicine approach can identify muscle and balance issues that can continue to plague an athlete even after present symptoms have resolved.
  4. Reports how a sports medicine approach can correct running form to help achieve long term pain free success.
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  • CPME (Credits: 0.75)

    PRESENT e-Learning Systems is approved by the Council on Podiatric Medical Education as a provider of continuing education in podiatric medicine. PRESENT e-Learning Systems has approved this activity for a maximum of 16 continuing education contact hours

    Release Date: 12/19/2018 Expiration Date: 12/31/2020

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  • Lecture Transcript
  • TAPE STARTS – [00:00]


    Speaker: Our next presenter, Dr. J. Spector, podiatric surgeon but the interesting thing is an elite athlete. If you are going to have somebody talk about sports medicine, you want somebody that knows about sports medicine. So 24 marathon, runs a sports medicine clinic and he is going to talk to us about the sports medicine and some new modality. Thank you.

    J. Spector: Good morning. J. Spector, I practice podiatry in the Atlanta area and my specialty is sports medicine. Little correction, as of last week I now have ran 25 marathons. So the picture that you see was last year at the foot of the Arizona bridge, I was the beginning of the third wave and I was in the front row and the army people were -- they formed a human starting line chain and funny thing is when the cannons went off because they have cannons in New York, you know, it's a big deal, I was in the lead for the first 400 meters and I am not really an elite athlete but I consider myself an athlete. But then my brain kicked in and said hey, you got to slow down a little bit. So I slowed it up. Last week, I ran New York again. So what I would like to discuss today are some three very common issues that we all deal with certainly in the sports world, plantar fasciitis, Achilles tinnitus and shin splints.

    [02:00]

    I want to give you sports medicine approach to that. Financial disclosure, I am a principal investigator for an Achilles tendon study that's being sponsored by MyMedics. What are the objectives of this talk? I want to discuss traditional all treatments for PF Achilles tendinitis and shin splints as well as new treatments based on evidence based research. Also I want to demonstrate how a sports medicine approach can identify muscle and balance issues that can continue to plague an athlete even after we've cured their pain symptoms. I also want to demonstrate how this approach can correct running form to help achieve long-term pain-free success. What are some of the old treatments? I think most of you have used these modalities and still probably do, NSAIDs, night splints, strappings, tapings, cortisone injections, typically one to three is common, orthosis, surgery, either open or endoscopic, which I think is really last resort, physical therapy, ultrasound and massage. So what are some of the new treatments? I still say there are some of the old treatments that are still in play. Using recumbent night splint, now using instead of trainer's tape using KT tape. We have all seen athletes like Olympic athletes using KT tape. It's not magical but it's very effective in its use.

    [04:00]

    Dry needling with physical therapy, PRP. There was a study done in 2013 by Martin Ellis in the International Orthopedics Journal. They had a 12-months followup after injection of PRP. Results were excellent; at 64%, good; at 14%, acceptable; and poor at 7%. The VAS score was significantly decreased from 7.1 at the beginning of treatment down to 1.9 at the last followup at 12 months. But it was a very small study, only 14 patients. So we have to keep some of these studies into its proper perspective. ESWT, extracorporeal shock wave therapy or simply shock wave therapy. Results of randomized placebo controlled multi-center study by Ludger Gerdesmeyer in the American Journal of Sports Medicine 2008 revealed a success rate of 72% after shock wave versus 44% after placebo. So I would say that was a pretty good success rate, pretty good outcome. Amniotic growth factor injections and orthotics. In terms of the amniotic growth factor injection, there is a phase three double-blinded study that began in January on plantar fascia and the Achilles tendon. So I think all of us are looking forward to seeing the outcome of that study in about a year or so.

    [06:00]

    Traditional Achilles tendon treatments, there really aren't a lot. There really have not been a lot. Physical therapy, heel lifts, NSAIDs, night splint and I would even add on there, CAM walker. What are some of the newer treatment? Again RICE, CAM walker, dry needling, PRP, shock wave therapy and amniotic growth factor injections. If you are to inject the Achilles tendon, there are basically three zones. So you have a proximal zone, mid body and distal or insertional. Has anybody ever injected an Achilles tendon? It's kind of scary because you certainly don't want to use cortisone because they could calcify and rupture. Also along with that, we all have to be careful of certain antibiotics. Cipro and Levaquin, I know I should not mention names, quinolones. There have been studies and in real life, I get about three to four patients a year who either get ruptures, partial rupture or inflammatory reactions on the Achilles tendon. So be very careful in prescribing some of these antibiotics, especially if the person is an athlete, if they are really going to stress the Achilles. Shin splints or the more current term is medial tibial stress syndrome.

    [08:03]

    Traditional treatments include ice, physical therapy, shock wave, orthosis. It kind of sounded like a broken record. So I have discussed some of the old treatments, some of the new treatments. So what's a sports medicine approach? How do we deal with our athletes who come in? People like myself run 50 miles a week, run marathons, have a full schedule, we are not going to stop. So telling them for -- I exclude certain things like stress fracture. You can't run through a stress fracture, but if a patient has plantar fasciitis, shin splints, Achilles tendinitis, we have to find other ways of getting them to run, getting them to stay moving because they are going to move in spite of us telling them, hey, take six weeks off. You just can't do that. So the first thing we have to do is we have to question our patients. What is your pre-run stretching routine? Is it static or dynamic? The typical static stretch is for runners. You go up against the wall. You do one of these, run or stretch, you may do this and hold it. You can get injured that way. So there is a real push to do something different and they are called dynamic stretches. Dynamic or active stretches. I am going to try to demonstrate that.

    [10:04]

    Thank you. You do leg swings. It's a pendulum. So equal forward, equal backward leg straight. Then you face whatever you are holding on to with two hands and you go sideways across the body. 10 on each side, forwards, backwards, across the body. Then the next thing we do are it's a routine, you walk on your heels, okay? About 30 meters, about 30 yards, walk on your heels then come back and you walk on your toes. The next thing I have people do typically are high knees. So you run high knees and you come back doing butt kicks. We do lots of things. Sometimes we will do something called the leg pull. You hold the leg up, you walk take a couple of steps, grab the other leg, hold it up and coming back, hold it up, okay? These are active stretches. What's the post-run stretching routine? I recommend static stretching for post-run routine. So that's when after you have ran and you are all warmed up, your muscles and tendons are warm, then you could do whatever kind of static stretch you want to do.

    [12:08]

    Any questions? Okay. Next question is, are you doing any kind of strength training? Are you strengthening your glutes? Are your strengthening your core? When you run, the power house of running are your glutes. The problem is when you do run even if you run 100 miles a week, you are not going to strengthen your glutes. So you have to do other things. You have to cross train. Core, I recommend, simply you could do planks and there are 20 varieties of planks to strengthen your abs. Shoe life, okay, so I get this all the time and I get like serious runner coming in how long you have had these shoes? Two years. You can't do that. Typical shoe life is 300 to 500 miles everyone wears them out a little differently based on your gait, based on your weight. So what happens is sometimes even the sole may still look good but that layer above what is known as EVA, they are now coming up with all different kinds of materials. But that part which you can't see or feel, it condenses. And once that part condenses, then you are losing support. So it's really important -- the biggest investment that athletes need to make, especially runners, are their shoes. That's a number one.

    [14:00]

    We may think that podiatrist they all need orthotics. They don't all need orthotics. I do believe for a lot of reasons people do but I always like to start with step-wise approach. So if a patient comes in and they are having mild symptoms, symptoms where you don't feel the need to do any kind of advanced treatment like shock wave or amniotic growth factor injection or even cortisone injection, the first thing that I would tell the patient to do is, hey change your shoes. And what I recommend is going to a specialty running store. They are all around. Some national chains like Fleet Feet. You all have these kind of stores. They go by different names wherever you live but for the most part, they usually know what they are doing. They know they are in the business of fitting people. It's a lost art but running shoes stores actually still do that. When we were kids, they used to do it in Buster Brown stores or wherever I know I am dating myself a little, but go to a specialty running store. If you are a casual athlete, I would tell them, hey, every six to eight months, the people who go -- who are doing cross fit, go to the gym, doing light running, six to eight months, you need to change your running shoes. If you are a serious runner, you go by mileage and most serious runners have watches, GPS watches that track everything and it's very easy to tell when it's time, 300 to 500 miles. Also I will add that sometimes people will come to you and they didn't have any sort of injury but they start feeling weird things in their feet. All of a sudden, they are feeling something that’s like a neuroma, temporarily while they are running but afterwards they don't feel it.

    [16:05]

    And you evaluate them. You see that they really don't have a neuroma but they are complaining of kind of nervy type symptoms. So I would say question them about their shoes and more often than not you are going to see that they should have changed their shoes. Have them change their shoes first. Work in a step-wise approach. Look at their shoes. Look at their -- are they doing any kind of strength training. Can we change how people run? A lot of times running form is the basis for them getting lower extremity injuries. So the answer is yes and how? We have all heard the term overstriding. Overstriding is basically the foot lands in front of the person's center of mass. This leads to a breaking impulse. That can lead to things like shin splints. The next phase of a shin splint, if a shin splints goes on for a long period of time, you have to look at possible stress fracture of the tibia. Happens -- in my world I see it a lot. We also see Achilles tendonitis, plantar fasciitis, and iliotibial band syndrome. I am sourcing out Richard Souza, physical therapist, who did an evidence based video tape running biomedical analysis. Take a look at this girl running. She is a really good runner.

    [18:01]

    And let's go back. Let me go back again. Freeze it. I am going to roll tape again on this. Freeze it, yeah. Right, keep going stop. No, keep going until heel touches the ground. Right there, okay. Now, what you see. Stopped at a little early but her leg was straight and she had what I call the checkmark sign or Nike Swoosh sign and the other thing to notice about her and she is a varsity cross-country runner. She is very fast girl. She is a high school junior. And see this elbow. That elbow is out. That elbow can't be out. And I will explain why in just a second. See the way her elbows going out and she is crossing over. Whenever you run, you never want -- I coach as well. I coach runner five days a week. So I always tell people make believe you have a piece of glass coming straight at you. If you going like this, you are going to break the glass with your hand. You can't do that.

    [20:02]

    Any of you watched Game of Thrones? There was a thing with Game of Thrones in the last season when Khaleesi said to John Snow bend the knee. What we saw what that girl, Jesse was, she was landing with her leg straight. Now I am going to go through a little demo with everybody and I have everybody do two things. Number one, can you guys stand up? I know it's almost break time but okay. I want everybody to jump up one inch off the ground and only land on your heel like this. Good. Doesn't feel good, right? Feel it all the way up to the neck. Now, I want everybody do a big jump and land with your knees bend. Doesn't that feel better? It's like 100 times better, right? Bend the knee. So when you land, when you are overstriding and you are landing with your foot in this position, you got that braking mechanism. That's what can lead to plantar fasciitis, Achilles tendinitis, shin splints. So if you simply change your patient's form and you are like, how am I going to do that? Right? So the people at Nike who have all the research dollars in the world basically came up with kind of simple but easy new way of helping people change their form.

    [22:03]

    If you are running with your elbow out like this, what happens is it's a balance thing. Your elbows coming out like this, your foot almost has to land like this in this position. So if you tell your patients to change the way just their upper body, here is another factor. If you are running like this with your arms in front of you, what happens is you are not moving your hips enough. So the idea what Nike came up with is if you get your arm back like this and you want to get back such that a lot of us have lines in our shirt, you want to have your fingers touch your shirt and come back this far. You don't want this, you want this. So when you are running, you want to be like this. And the most important thing is pulling your arm back not forward. Sprinters will go forward but people who are just running whether they run two miles or 10 miles, you have to go back. If you go back what you are doing is you are engaging your shoulders. By getting your shoulders moving more, you are going to get your hips to move more and then you are going to be running with your glutes and that is the key. Get those glutes working. Very simple. In two minutes, you can get somebody doing the right thing. I had a patient yesterday. Classic, he is a 41-year-old. He runs and he plays tennis. He is not just a regular runner like he ran in high school and college and he is about 6 feet 3 inches. He is a big guy, but he keeps getting these calf pain like just above the Achilles and now it's getting into the proximal Achilles, and he has had this for five years, went to a different-profession doctor about six weeks ago who spent two minutes with him, sent him to physical therapy and off he went.

    [24:17]

    But he has had this thing go on and on and on. I videoed him yesterday. He looked pretty much like that girl, Jesse. It's the same thing. He had the classic overstriding, heel strike and I said, look. I said, we could do shock wave on your Achilles but I think longterm I could solve your problem and I am really glad that you are overstriding and that your form is off because I could actually do something longterm to help you. So I literally spent three minutes with him said just get like this and I re-videoed him and there he was bending his knee and he just texted me this morning that he ran three miles at seven-minute pace. It's a very good clip and he said he was pain-free. He said he had to think about it all the time which you do. I have been there myself. I can't remember exactly who the research was no this but they said something like 83% of all runners overstride. So that's a very big, it's a very big group. Very big group of people that are going to come to podiatrist. So we could really help them. Just remember pull the arm back, tuck in your elbows, no elbows out like this and I promise you, you will be able to help them longterm. Same girl, Jesse, girl in front here. That was two weeks after I worked with her and by the way she had terrible shin splints, horrendous shin splints to the point where she was close to getting a stress fracture.

    [26:07]

    Look at that knee. That knee is bent and look at her body lean. She is doing everything correctly. I seem to be missing some slides, I don't know. That's just me and my family. I had a slide up there that was taken last week of the New York City marathon runners and they are all arms back, knees bent. It’s a beautiful thing. There is one other test that I want to go over with you and then you guys will have your break. Stand up again. I put my patients through this test as well. It's balance testing. So you put your hands no your waist, stand on one leg for 30 seconds. Now, I just saw him doing it. I am not picking on you but when you start seeing somebody surfing, doing the weeble wobble, then what does that tell you, they are weak. You guys can sit. They are weak in their glutes. I don't know if you guys have ever heard, speak or heard of Jay Dicharry. He is a physical therapist, brilliant mind, wrote a book called anatomy of running, which I really recommend. It's very eye opening in terms of biomechanics. I would call more modern day biomechanics and what he says is that this is like a single leg stance. It's equivalent to the single leg stance phase of gait. So running or walking is a series of going like this. If you are weak in your glutes, you are not going to have the proper balance.

    [28:02]

    So one thing that I tell my patients to do when we see that weakness. So you put them 30 seconds left and 30 second right. You can even go as far as to have you do that and then you have them close their eyes and do it. It makes it a lot more challenging. But all they have to do is home exercise. They don't have to have a gym membership to do this. Just three things they need to do. Air squats, they look like this and you want to do 25 air squats. Then you want to do walking lunges. So walking lunges, tap the back of knee to the floor. And you basically go from -- this is a good distance from here where that microphone stand is. Then you have them do a plank. They get down in kind of like push-up position on their elbows keeping their back flat, rear end flat. You want to build up to one to two minutes. You do three sets of that and they could do that every other day and they could do it at home. Very, very simple, easy cross training. It can take up to 12 weeks until you actually elicit a real true change in terms of strength. So keep that in mind. That's all I got for you today. Any questions?

    [Applause]

    Speaker 1: I have got two short questions.

    Dr. Spector: Sure, go ahead.

    Speaker 1: For the young athlete adolescent. They play soccer and that kind of thing. So I can see that doing those dynamic type stretching, they would be more motivated to do those types of exercises. I mean is there anything else you could suggest to encourage that type of patients to do. That's a first question.

    Dr. Spector: To add to it so they could do these.

    [30:00]

    Dr. Spector: They call it Frankenstein. A newer one that we also do is karaoke. It looks like they are dancing. So they go like this back and forth. Skips for distance, skips for height. So skips for height, you like [indecipherable] [00:30:25] skip for distance, you are going further. Second question.

    Speaker 1: Second question is concerning plantar fasciitis. And I noticed it many patients when they walk, they don’t actively use their toes. So I know you can change that with an orthotic or shoe. Do you have any suggestions in that regard if you notice that there could be some weakness of intrinsic muscles of the foot or leg?

    Dr. Spector: Yes. I don't know if you guys know what podiatrist who is in the Portland area, Ray McClanahan. Ray McClanahan has YouTube videos on strengthening toes. So look him up. I believe his -- if you go to correct toes and there is two T's correcttoes.com, you will see those exercises and I always tell my patient to look those up. Correct toes. Ray McClanahan. He is a rising star certainly in sports medicine. Any other questions? Okay, I thank you.

    Speaker: Thank you. Very, very good.



    TAPE ENDS - [31:54]