DR. PAUL MALOOF MD TIDEWATER ORTHOPAEDICS

Transcription

1 DR. PAUL MALOOF MD TIDEWATER ORTHOPAEDICS

2 Foot and Ankle Injuries in the Endurance Athlete Paul Maloof, MD Orthopaedic Surgeon Foot and Ankle Specialist

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4 Duke University Medical Center June 25, 2013

5 Tidewater Orthopaedic Associates The Specialists Group 901 Enterprise Pkwy Hampton, VA Monticello Ave Williamsburg, VA

6 Objective Identify common running injuries of the foot and ankle Differentiate sources of pain Discuss common findings of Stress Fractures Shin Splints Achilles Tendinitis Plantar fasciitis Ankle Sprains

7 Goal Educate our running population about common injuries that are related to running and how to prevent injury. Lecture is not intended to treat, diagnose, or cure any injury you may have.

8 Anatomy Forefoot Metatarsals Toes Midfoot Navicular Cuneiforms Cuboid Hindfoot Talus Calcaneus

9 Anatomy 28 Bones 33 Joints Over 100 Tendons, Muscles, and Ligaments Netter Atlas of Human Anatomy

10 Stress Fractures More than 50% of all stress fractures occur in the lower leg Most common sites are the 2 nd /3 rd metatarsals

11 Affects people of all ages. Stress Fractures Seen in athletes who participate in high-impact activities with repetitive foot strike. Distance running Basketball Track and field Tennis Gymnastics

12 Stress Fractures What are they. Overuse injury Muscles fatigue during exercise Unable to absorb added stress Fatigued muscle transfers energy to the bone stress overload Small cracks or fractures

13 Causes Conditioning Too much too soon Increase frequency Increased duration Increased intensity Equipment Shoes ( or lack of) Unfamiliar surface Technique Errors in training Altered mechanics Bone Insufficiency Weak bone Stress Fractures

14 Females more than males Less protective muscle mass Irregular hormonal cycles Decrease bone density Female athlete triad Eating disorders Irregular menstrual cycle Osteoporosis Stress Fractures

15 Stress Fractures Signs and Symptoms Pain Develops gradually Worse with weight bearing activity Lessens with rest Becomes more severe with normal, daily activities Swelling Top of foot Outside of ankle Tenderness to touch at site of the fracture Possible bruising/discoloration

16 Initial Treatment REST, REST, REST!!!!!!!! Take a break 6-8 weeks for bone to heal Cross-train Ice, Compression, Elevation Protective footwear Casts Surgery Stress Fractures Goal To help you return to your previous activity level

17 Stress Fractures Prevention Gradual increase any new sports activity Don t be a weekend warrior! Gradually increase time, speed, and distance Maintain a healthy diet Foods rich in Calcium and Vitamin D Help build bone strength Do not wear old or worn running shoes Cross-training Change it up! Strength training Helps prevent early muscle fatigue and prevent the loss of bone density that comes with aging If continued pain persists, see an orthopedic surgeon

18 Shin Splints What are they. Common exercise-related problem Pain along the inner border of the shinbone (tibia) Medial tibial stress syndrome Inflammation of soft tissues surrounding tibia Muscles Tendons Periosteum

19 Shin Splints Causes Sudden changes in physical activity Frequency Duration Intensity Running downhill Plantar-flexed foot Flat feet or Rigid, high arches Increases stress on lower leg muscles during exercise Training with improper or worn-out shoes

20 Shin Splints Signs and Symptoms Gradual onset of symptoms Lower leg pain Sharp and razor-like Dull and throbbing Pain when the foot or toes are bend downward Mild swelling Tenderness Front or inner part of the lower leg Pain that subsides initially when not exercising Later becomes continuous Lumps and bumps over the bone

21 Shin Splints Treatment Rest May take several weeks of rest from the activity that caused the pain Cross-training Ice 20 minutes at at time several times/day Compression May prevent additional swelling Elevation Non-steroidal anti-inflammatory drugs Ibuprofen, Aspirin, Naproxen Orthotics Flat feet or recurrent shin splints Help align and stabilize foot and ankle Takes stress off of lower leg Supportive shoes Good cushioned shoe will help reduce stress on your shins Flexibility exercises Stretching your lower leg muscles may relieve your symptoms

22 Shin Splints Prevention Avoid sudden, dramatic changes in exercise duration, intensity, frequency, and location 10% rule Run on softer surfaces Replace running shoes every miles Consider a pair of off-the-shelf orthotics to help prevent overpronation (ankle rolling inward) Cross-train in sports or activities that place less stress on the lower leg Cycling, swimming, walking

23 Largest tendon in the body Connects calf muscles to heel bone Instrumental to walk, run, and jump Prone to overuse injuries Tendinitis Degeneration Achilles Tendon

24 Achilles Tendinitis What is it? Inflammation of the tendon Swelling Pain Irritation 2 types Non-insertional Insertional

25 Involves lower portion of the tendon Bone spurs often form where the heel attaches to the bone Tendon can harden Calcify Can occur at any time No association with activity Insertional Achilles Tendinitis

26 Middle portion of the tendon Tendon breakdown Tiny tears Swelling Thickening More commonly affects younger, active people Tendon may become hard Calcify Non-Insertional Achilles Tendinitis

27 Achilles Tendinitis Causes Repetitive stress to the tendon Typically not related to a specific injury Too much, too soon Sudden increase in activity Amount Intensity Excessive hill running or a sudden addition of hills and speed work Tight calf muscles Places extra stress on the Achilles tendon Bone spurs Extra bone growth can rub against tendon and cause pain

28 Achilles Tendinitis Common symptoms Pain and stiffness in the morning Pain that worsens with activity Severe pain the day after exercising Thickening of the tendon Bone spur formation Swelling Present all the time but worsens with activity Redness over the skin You can sometimes feel a spongy feeling when you press your fingers into the tendon and move the foot This is fluid within the tendon sheath

29 Achilles Tendinitis Treatment Rest 1 st step Rest for 2 weeks after the aggravating activity Decrease or stop activities that make pain worse Cross-train Switch from high-impact to low-impact activities Ice Place on most painful areas Immediately after exercise or as needed throughout the day 20 minutes on, 20 minutes off Anti-inflammatories Ibuprofen, Naproxen, etc. Reduce pain and swelling Will NOT reduce thickening of already damaged/degenerated tendon

30 Achilles Tendinitis Treatment Physical Therapy Proven to work better for noninsertional than insertional tendinitis Eccentric strengthening program Bilateral heel drop Single leg heel drop Supportive shoes and orthotics Softer shoes at the back of the heel or backless shoes Reduces irritation Achilles Silicone sleeve Reduces irritation Heel lifts More appropriate for insertionalachilles tendinitis Takes strain off the tendon Can move heel away from the back of the shoe Walking boot Give tendon a chance to rest before beginning therapy Cortisone injections NO, NO, NO!!! Can weaken tendon and lead to rupture.

31 Prevention Achilles Tendinitis Regularly stretch the posterior calf muscles Increase training gradually

32 Plantar Fasciitis What is it? Plantar fascia Long, thin ligament Bottom of foot Lies directly under the skin Connects the heel to the front of your foot Supports the arch of your foot Plantar fascia can become irritated and inflamed Plantar fasciitis Most common cause of pain in the foot ~2,000,000 people treated for this condition annually

33 Plantar Fasciitis Risk factors Tight calf muscles Make it difficult to flex your foot toward your shin Increases stress on plantar fascia Obesity or sudden increase in weight Very high arches Repetitive high-impact activity Running, aerobics, etc. New or increased activity Weak foot muscles Poor shoe support

34 Heel spurs do NOT cause plantar fasciitis pain Heel Spurs 1/10 people has heel spurs 1/20 people with heel spurs has foot pain Spur is not the cause of pain No removal is necessary

35 Plantar Fasciitis Signs and Symptoms Pain on the bottom of the foot near the heel Heel pain that is worse in the morning with the first few steps Or after a long period of rest Start up pain Pain seems to improve after initiating activity Pain gradually worsens Since it is difficult to rest the foot Greater pain after (not during) exercise or activity

36 Plantar Fasciitis Treatment Rest Temporary decrease or cessation in training Ice Rolling foot over frozen water bottle 20 minutes 3-4 times/day Anti-inflammatory medication Ibuprofen, Naproxen, etc. Reduce pain and inflammation Physical therapy and stretching Stretching calves and plantar fascia is the most effective way to relieve the pain that comes with this condition Calf Stretch Plantar fascia stretch

37 Plantar Fasciitis Treatment Supportive shoes and orthotics Thick soles and extra cushioning can reduce pain with standing and walking Reduces tension and the micro-trauma that occurs with every step Soft silicone heel pads Inexpensive Elevate and cushion the heel Symptom relief Pre-made or custom orthotics are also helpful Night splints Stretches plantar fascia while sleeping Very effective

38 Plantar Fasciitis Prevention Wear orthotics to prevent excess pronation and prevent inflammation of the plantar fascia and continued tearing of the fascia Stretch regularly

39 Ankle Sprain Extremely common 30% of athletic injuries Lateral ankle 85% of all sprains Inversion, internal rotation

40 Lateral Ankle Ligaments

41 Lateral Ankle Ligaments Popping or tearing Audible noise occasionally Loss of support

42 Lateral Ankle Ligaments Functional Treatment Rest Ice Compression Elevation NSAID s useful Ibuprofen, Aleve

43 Ankle Sprain Treatment Rehabilitation Range of motion Achilles stretching Peroneal strengthening Proprioception training Bracing/taping Time to return to sport Depends on severity of injury

44 Summary Most mild conditions will resolve with conservative treatment as outlined above For conditions that persist or are refractory to conservative treatment, evaluation and treatment by a professional may be warranted

45 Questions?